Coring knife

ABSTRACT

A coring knife can be used to make a circular incision. The coring knife can include an abutment that can be inserted into heart tissue. The circular incision is made by pressing the circular cutting edge of the coring knife against the abutment.

CROSS-REFERENCE TO RELATED APPLICATION

This application is a continuation of Ser. No. 12/945,890, filed Nov.14, 2010, which is a continuation-in-part of application Ser. No.12/590,863, filed Nov. 15, 2009, and Ser. No. 12/590,864, filed Nov. 15,2009, which are incorporated herein by reference.

BACKGROUND OF THE INVENTION

1. Field of the Invention

This invention relates to the field of heart assist devices and methods,devices and systems for the in vivo implantation of VADs and itsattachment to the heart.

2. Description of the Related Art

Heart assist devices are implantable devices that assist the heart incirculating blood in the body. A ventricular assist device (VAD) is anexample of a heart assist device that is used to assist one or bothventricles of the heart to circulate blood. For patients suffering fromheart failure, assisting the left ventricle with a VAD is more common.Currently, VADs are commonly used as a treatment option or a bridge totransplant for patients with heart failure.

The procedure to implant VADs carries many risks and side effects. Theimplantation procedure is invasive as surgeons need to access the heartdirectly by opening the chest with a sternotomy or a thoracotomy.Generally, a heart-lung bypass machine is used during the procedure, buta beating heart procedure may minimize side effects associated withusing a heart-lung bypass machine in such a major invasive surgery.However, a beating heart procedure can potentially lead to significantblood loss during the process of implanting the VAD if great care is notexercised.

While procedural related issues during the implantation process candirectly impact the success of the implantation, some of theseprocedural issues may also impact patients' recovery. When complicationsarise during the implantation process, the recovery time for these veryill patients can be extended. Procedural issues may result in majordetrimental side effects for patients, directly increasing the recoverytime. The recovery time and risk factors are often compounded by theoriginally poor health of the heart failure patient in need of the VAD.

A system and method for implanting a ventricular assist device without asternotomy is desired. Furthermore, a system and method for safelyimplanting a VAD without requiring heart-lung bypass is desired.Additionally, a system and method for implanting a ventricular assistdevice in a beating-heart procedure is desired.

SUMMARY OF THE INVENTION

Briefly and in general terms, the present invention is directed to acoring knife. In aspects of the present invention, a coring knifecomprises a coring blade including a cylindrical wall defining acircular cutting edge and a hollow interior, and a coring abutmentlocated forward of the cutting edge, the coring abutment attached to asupport extending into the coring blade, wherein the cutting edge andthe coring abutment are movable relative to each other.

In other aspects of the present invention, a coring knife comprises acoring blade including a cylindrical wall defining a circular cuttingedge and a hollow interior, a coring abutment attached to a supportextending into the coring blade, and a coring knife casing containingthe coring blade, wherein the coring blade is configured to extend outof the coring knife casing and toward the coring abutment, and thecoring knife casing includes a stop feature configured to fit in analignment feature of a separate device for aligning the coring knifeprior to extension of the coring blade out of the coring knife casing.

In other aspects of the present invention, a coring knife comprises agrip, a coring abutment connected to the grip, and a slide assemblyconnected to a grip, the slide assembly including a coring blade with acircular cutting edge and a coring knife casing containing the coringblade, the coring blade configured to extend out of the coring knifecasing, the coring knife casing configured to be selectively positionedand locked at any one of a plurality of locations between the grip andthe coring abutment prior to extension of the coring blade out of thecoring knife casing.

The features and advantages of the invention will be more readilyunderstood from the following detailed description which should be readin conjunction with the accompanying drawings.

BRIEF DESCRIPTION OF THE FIGURES

FIG. 1 illustrates a variation of the ventricular assist system.

FIGS. 2a and 2b are perspective and sectional views of a variation ofthe attachment ring attached to the valvular structure.

FIG. 3a is a perspective view of a variation of the attachment ring.

FIG. 3b is a cross-sectional view of A-A of FIG. 3 a.

FIG. 4a is a perspective view of a variation of the attachment ring.

FIG. 4b is a cross-sectional view of FIG. 4 a.

FIG. 5 illustrates a variation of the clamp.

FIGS. 6a and 6b illustrate a variation of the clamp in opened and closedconfigurations, respectively.

FIGS. 7a and 7b illustrate a variation of the clamp on the attachmentring with the clamp in opened and closed configurations, respectively.

FIG. 8a illustrates a variation of the attachment ring attached to theinflow conduit.

FIG. 8b is a perspective view of section B-B of FIG. 8 a.

FIG. 8c is the variation of cross-section B-B of FIG. 8a shown in FIG. 8b.

FIG. 9a illustrates a variation of the attachment ring attached to theinflow conduit.

FIG. 9b is a perspective view of section B′-B′ of FIG. 9 a.

FIG. 9c is the variation of cross-section B′-B′ of FIG. 9a shown in FIG.9 b.

FIGS. 10a and 10b are a perspective views of a variation of the valvularstructure.

FIGS. 10c-10e are perspective views of a variation of section C-C.

FIGS. 11a through 11c are bottom perspective, top perspective, and topviews, respectively, of a variation of the valvular structure.

FIGS. 12a and 12b illustrate perspective and section views,respectively, of a variation of the valve in a closed configuration.

FIG. 12c is a perspective view of the valve of FIGS. 12a and 12b in anopen configuration.

FIGS. 13a and 13b are top perspective and bottom perspective views of avariation of the valve in a closed configuration.

FIGS. 13c and 13d are top perspective views of the valve of FIGS. 13aand 13b in open configurations.

FIGS. 14a and 14b are top perspective and bottom perspective views of avariation of the valve.

FIGS. 15a and 15b are top perspective and bottom perspective views of avariation of the valve.

FIGS. 15c through 15e illustrate variations of miter valves.

FIG. 15f illustrates a variation of a duckbill diaphragm valve.

FIGS. 16a and 16b illustrate open and closed configurations,respectively, of a variation of the valvular structure of section C-C.

FIGS. 17a and 17b illustrate open and closed configurations,respectively, of a variation of the valvular structure of section C-C.

FIGS. 18a and 18b are exploded and top views of a variation of thevalve.

FIGS. 19a and 19b are perspective and sectional views of a variation ofthe valve integrated with an attachment ring.

FIGS. 19c and 19d are perspective and sectional views of a variation ofthe valve integrated with an attachment ring.

FIG. 20 illustrates a variation of the attachment ring and an explodedview of a variation of the valvular structure.

FIG. 21a is a top perspective view of a variation of the valve.

FIG. 21b is a variation of cross-section D-D of the valve.

FIG. 21c is a bottom perspective view of the valve of FIG. 21a with thediaphragm flap shown in see-through.

FIG. 22 is a sectional view of a variation of the valvular structure.

FIG. 23 illustrates a variation of the valvular structure with thehousing shown in see-through.

FIG. 24 illustrates a variation of the valvular structure with thehousing in see-through.

FIG. 25 is a sectional view of a variation of a method for attaching thevalvular structure to the attachment ring.

FIGS. 26a and 26b are sectional views of a variation of a method forattaching the valvular structure to the attachment ring.

FIGS. 27a and 27b illustrate a variation of the method process flow forimplanting a variation of the ventricular assist system.

FIGS. 28a and 28b illustrate variations of a method for accessing thetarget site.

FIG. 29a illustrates a variation of the tunneler.

FIGS. 29b and 29c illustrate variations of the tunneler of FIG. 29a withthe bullet tip removed.

FIG. 30a illustrates a variation of the tunneler.

FIG. 30b illustrates the tunneler of FIG. 30a with the outer sheathremoved from the tunneler shaft.

FIG. 31 illustrates a variation of the tunneler attached to the outflowconduit.

FIG. 32 illustrates a variation of inserting the outflow conduit in thetarget site.

FIG. 33a through 33c illustrate a variation of a method for anastomosingthe aorta to the outflow conduit.

FIG. 34a illustrates blood flow through the outflow conduit after aorticanastomosis.

FIGS. 34b through 34d illustrate variations of methods for stanchingblood flow through the outflow conduit.

FIG. 35 illustrates a variation of a method of attaching the attachmentring to the apex of the heart.

FIGS. 36a and 36c are perspective and side views, respectively, of avariation of the coring knife.

FIGS. 36b and 36d are perspective and side views of a variation ofsection F-F of FIG. 36 a.

FIG. 36e is a side view of a variation of section F-F of FIG. 36a withthe coring blade in a retracted configuration.

FIGS. 37a and 37b are perspective and sectional views, respectively, ofa variation of the coring knife.

FIGS. 37c and 37d are front views of the coring knife with the coringabutment in a rotated configuration, and the coring blade in an extendedconfiguration, respectively.

FIG. 38 illustrates a variation of the coring knife.

FIG. 39a is a side view with the valvular structure shown in cut-away,of a variation of a method of using the coring knife with the valvularstructure.

FIG. 39b is a perspective end view of FIG. 39 a.

FIGS. 40a through 40i illustrate a variation of a method for using avariation of the ventricular assist device system.

FIGS. 41a through 41d illustrate a variation of a method for coring.

FIGS. 42a through 42c illustrate a variation of inserting the inflowconduit through the attachment ring.

FIGS. 43a and 43b illustrate a variation of a method for stanching bloodflow through the pump outflow elbow and de-airing the pump.

FIG. 44 illustrates a variation of a method for de-airing theventricular assist device.

FIG. 45 illustrates a variation of attaching the pump to the outflowconduit.

FIGS. 46a-46d show an attachment ring, FIGS. 46b and 46d being partialcross-sectional sectional views.

FIGS. 47a-47c show an attachment ring, FIG. 47a showing a flat sheet ofmaterial used for making the attachment ring.

FIGS. 48a-48d show an embodiment an attachment ring with an integralvalve.

FIGS. 49a-49d are perspective views of a clamp for use on an attachmentring, FIG. 49d showing clamp closed on an attachment ring.

FIGS. 50a and 50b are plan and perspective views of a clamp for use onan attachment ring, showing ratcheting teeth for locking the clampclosed.

FIG. 51 is a plan view of a clamp for use on an attaching ring with onepair of teeth.

FIGS. 52a-52c are perspective and cross-sectional views of a slittingtool for making a linear incision in the heart, the linear incisionallow for a subsequent circular incision.

FIGS. 53a-53f are perspective and partial plan views of a coring knifefor making a circular incision in the heart.

FIG. 54 is a partial plan view of a portion of a coring knife, showing avariation on the coring knife casing.

FIG. 55 is a partial plan view of a portion of a coring knife, showing avariation on the coring knife abutment.

FIGS. 56a-56d are perspective and proximal plan views of a valvularstructure having a spring-loaded hinge.

FIGS. 57a-57d are perspective and plan views of a valvular structurehaving two identical halves, FIGS. 57c and 57d showing view of thedistal end.

FIGS. 58a-58e are perspective, plan and side views of a C clamp forengaging a valvular structure onto an attachment ring.

FIGS. 59a and 59b are perspective views showing the C-clamp with anattachment ring and valvular structure.

FIGS. 60a-60e are perspective, cross-sectional and partial side views ofvarious aortic punches.

FIGS. 61a and 61b are perspective views of anatomical vessels with holesmade by aortic punches.

FIGS. 62a-62d, 63a-63d, 64a-64d and 65a-65d are perspective views ofvarious coring knives.

DETAILED DESCRIPTION

As used herein, any term of approximation such as, without limitation,near, about, approximately, substantially, essentially and the like meanthat the word or phrase modified by the term of approximation need notbe exactly that which is written but may vary from that writtendescription to some extent. The extent to which the description may varywill depend on how great a change can be instituted and have one ofordinary skill in the art recognize the modified version as still havingthe properties, characteristics and capabilities of the modified word orphrase. For example without limitation, something that is described as“substantially circular” in shape refers to a shape that is perfectlycircular and a shape that one skilled in the art would readily recognizeas being circular even though diameters measured at multiple locationson the circle are not exactly the same. As another non-limiting example,a first structure that is described as “substantially parallel” inreference to a second structure encompasses an orientation that isperfectly parallel and an orientation that one skilled in the art wouldreadily recognize as being parallel even though distances betweencorresponding locations on the two respective structures are not exactlythe same. In general, but with the preceding discussion in mind, anumerical value herein that is modified by a word of approximation mayvary from the stated value by ±15%, unless expressly stated otherwise.

Variations of a system and method for implanting a VAD during abeating-heart procedure are disclosed. The system can minimize orprevent blood loss from the heart during the system implantationprocedure, notably during the steps of coring a portion of theepicardial wall and insertion of the inflow conduit through theepicardial wall. The system can provide a fluid-tight seal around thesurgical tools used to access or come into contact with the internalfluid volume of the heart. Throughout this disclosure, one shouldappreciate that references made to VADs equally applies to all heartassist devices. Similarly, the system and surgical tools may apply to asimilar procedure of cannulation to other parts of the heart or of thecardiovascular system.

FIG. 1 illustrates a ventricular assist device (VAD) system 13 with apump 8. All locations described as proximal or distal, herein, arerelative to the location of the pump 8. The pump 8 can draw blood fromthe left ventricle, and deliver the blood to the aorta at a higherpressure to assist the pumping of the heart. The pump 8 is configured todirect blood flow from one location (e.g., the heart) to a secondlocation (e.g., target vasculature like an aorta) in the vascular systemto provide mechanical circulatory support/assistance. For example, thepump 8 can be configured as a unidirectional turbine pump 8 to directblood from the inflow side of the pump 8 (e.g., from the heart) to theoutflow side of the pump 8 (e.g., to the aorta). A percutaneous lead 5having insulated wires can be used for transmission and/or receiving ofdata and/or power between the pump 8 and a controller and/or a remotedevice for controlling the operation of the pump 8. In one variation, acontroller or remote is outside of the patient's body. The pump 8 canhave any configuration including but not limited to having axial flow orcentrifugal flow.

The pump 8 can be directly attached to or have an inflow conduit 10 at afirst end of the pump 8 and directly attached to or have an outflowconduit 2 at a second end of the pump 8. The inflow conduit 10 can becoupled with the pump 8 by a helically threaded coupler configured toattach to the inflow port 7 of the pump 8.

The inflow conduit 10 can have a hollow channel for fluid communicationsuch as directing blood from a first location (e.g., the heart) to thepump 8. In one variation, the inflow conduit 10 can be flexible. Inanother variation, the inflow conduit 10 can be rigid, such as a metaltube. In yet another variation, the inflow conduit 10 may have acombination of rigid and flexible elements such as having a proximal(relative to the pump 8) rigid elbow for coupling with the pump 8 thatis connected to a flexible middle portion to accommodate for bending anda distal rigid portion (relative to the pump 8) for coupling with theheart. The inflow conduit may also be formed by a portion of the pumpbody.

As illustrated in FIG. 1, the inflow conduit 10 has a distal end thatcan be placed through the valvular structure 12 and the attachment ring22 before entering into the heart after implantation. A flexible middleportion of the inflow conduit 10 provides strain relief between thedistal end and the proximal end. The proximal end is coupled with thepump 8. Blood can enter the inflow conduit 10 through its distalopening, travel along the length of the inflow conduit 10, and enter thepump 8 at the inflow port 7 of the pump 8 after exiting the proximalopening of the inflow conduit 10. The inflow conduit 10 can be integralwith, or separate and attachable to, the pump 8.

The valvular structure 12 is configured to prevent or minimize bloodloss from the heart during the implantation of the VAD. The valvularstructure 12 can be removed from the system and the patient once theinflow conduit 10 is properly positioned relative to the heart, forexample, after the inflow conduit 10 has been inserted into theattachment ring 22. The valvular structure 12 can seal against a coringknife and/or the inflow conduit 10 which passes through a channelthrough the valvular structure 12. The valvular structure 12 canminimize or prevent blood flow out from the heart during theimplantation of the VAD. Additionally the valvular structure 12 canprovide for passage of other instruments during the procedure whilepreventing blood loss out of the heart.

The valvular structure 12 can be directly attached to an attachment ring22, for example, indirectly attaching the valvular structure 12 to theapex of the heart during use. The attachment ring 22 can be configuredto connect to a ventricle. The attachment ring 22 can fix and sealagainst the inflow conduit 10 once the VAD is implanted. The attachmentring 22 can be a ventricle or heart connector. The attachment ring 22can fixedly attach to the VAD to the wall of the heart. Thus, theattachment ring 22 is configured to be secured against the heart, and isalso configured to be secured against the inflow conduit 10.

An outflow conduit is coupled to the second end (e.g., outflow port) ofthe pump 8 where the blood or fluid exits the pump 8. In an axial flowpump arrangement, the outflow conduit 2 is approximately linear andopposite to the inflow conduit 10. Similar to the inflow conduit 10, aproximal end (relative to the pump 8) of the outflow conduit 2 iscoupled to the pump 8, whereas the distal end (relative to the pump 8)of the outflow conduit 2 is for coupling to a target vasculature (e.g.,aorta) where blood re-enters the circulatory system after exiting thepump 8.

Similar also to the inflow conduit 10, the proximal end of the outflowconduit 2 can be rigid for coupling to the pump 8. The middle portion ofthe outflow conduit 2 can be made from a flexible material for bendrelief. In one variation, the distal portion of the outflow conduit 2(relative to the pump 8) can be a flexible sealed graft that can be sewnonto a target vasculature (e.g., aorta) by way of an anastomosis, forblood to re-enter the circulatory system.

The ventricular assist system can have fluid communication between theinflow port 7, the inflow conduit 10, the pump 8, the outflow conduit 2and the outflow port. The components of the ventricular assist systemshown in FIG. 1, except for the valvular structure 12, can all orpartially be from a Heartmate II Left Ventricular Assist Device (fromThoratec Corporation, Pleasanton, Calif.).

FIGS. 2a and 2b illustrate a valvular structure 12. In conjunction withother components in a system, this valvular structure 12 helps toprevent or otherwise minimize blood loss out of the heart during theimplantation or cannulation procedure, for example, when an opening iscreated in the heart while the heart is beating, or when a heart-lungby-pass machine is not used. The valvular structure 12 has a housing 18that can be substantially cylindrical with a valve 16 and/or one or moreseals 17 coupled to the inside wall of the structure. The valve 16 canact as either a complete or a partial seal for the valvular structure12. The valve 16 can allow the flow of fluid or entry of an element in adistal direction and substantially impair or completely prevent the flowof fluid or entry of an element in a proximal direction. The housing 18and valve 16 can be configured to be attachable to and removable fromthe attachment ring 22. The housing 18 can be separatable and removablefrom the valve 16. The housing 18 can have an attachment ring channel 14around the inner circumference of the housing 18. The attachment ring 22can be positioned inside of the attachment ring channel 14 and at ornear one end of the housing 18. The attachment ring 22 and valvularstructure 12 can have longitudinal axes 187. The longitudinal axis ofthe attachment ring 22 and the longitudinal axis of the valvularstructure 12 can be co-axial.

A de-airing channel 15 can be configured through the wall of the housing18. In the process of cannulation or implantation, air can be introducedinto the valvular structure 12. Air entering the circulatory system cancause air embolism and can be harmful to a patient. The de-airingchannel 15 can be used for purging all the air from the valvularstructure 12 prior to insertion of the inflow conduit 10 into the heartthus preventing air from entering the circulatory system. In onevariation, suction can be applied to and/or a fluid such as salineand/or blood can be delivered through the de-airing channel 15 to removeair from the system before the system is completely assembled. Thede-airing channel 15 can place the environment radially external to thesurface of the housing 18 in fluid communication with the attachmentring channel 14.

FIGS. 3a and 3b illustrate an attachment ring 22. The attachment ring 22can be attached to the epicardial wall, for example, by sutures throughthe cuffs 19 and 21 and the epicardial wall. After being sutured to theheart, the cuffs 19 and 21 can provide at least mechanical support onthe heart wall for the attachment ring 22, which serves as an anchoringpoint for securing of the inflow conduit 10 after it has been insertedinto the heart for fluid (e.g., blood) communication. The attachmentring 22 can have an attachment ring wall 29 that defines an attachmentring channel 14. The attachment ring channel 14 can be open at bothends. The inflow conduit 10 can be passed through the attachment ringchannel 14, accessing the chamber inside the ventricle. The attachmentring 22 can have a substantial or nominal height. The attachment ringwall 29 can be made from a silicone molded body with ABS, Delrin, orcombinations thereof. The attachment ring 22 can have polypropylene ringinserts (e.g., to provide circular structure to facilitate tool andinflow conduit 10 insertion) and reinforced polyester mesh (e.g., toprevent tearing). The attachment ring wall 29 can be sutured to the cuff19 and/or 21. The cuff pad 20 can be made from PTFE felt.titanium,silicone, or combinations thereof. The attachment ring 22 can be fromabout 5 mm to about 25 mm tall. The attachment ring wall 29 can have athickness from about 1 to about 3 mm (e.g., not including flanges). Thediameter of the attachment ring channel 14 can range from about 10 mm toabout 25 mm.

The attachment ring wall 29 can have a distal band 31 extending radiallyfrom the attachment ring wall 29 at or near the distal terminus of theattachment ring wall 29. The distal band 31 can be integral with theattachment ring wall 29. The distal band 31 can attach to the distaland/or proximal cuff 21. The attachment ring wall 29 can have a proximalband 26 at or near the proximal terminus of the attachment ring wall 29to maintaining a substantially circular cross-section adjacent to wherethe inflow conduit 10 is inserted into the attachment ring channel 14.The proximal band 26 can be a rigid metal or plastic. The proximal band26 can structurally reinforce the proximal end of the attachment ringwall 29. The attachment ring wall 29 can be flexible or rigid. Theseproximal and distal bands 26 and 31 can be used as anchors, attachmentpoints, visual alignment indicators and/or locks to other structures,components, or tools used in the implantation process.

The attachment ring 22 can be attached to the heart by stitching,suturing, or stapling one or more regions on the cuff 19 and/or 21 ofthe attachment ring 22 to the heart. The attachment ring wall 29 isattached to the cuff 19 and/or 21 having an annular shape with a distalcuff 19 or sewing region and a proximal cuff 21 or sewing region. Forexample, the cuffs 19 and/or 21 can be attached to the attachment ring22 by sutures, thread, staples, brads, welding, adhesive, epoxy, orcombinations thereof. The cuffs 19 and 21 extend radially from theattachment ring wall 29 outward. The distal cuff 19 can extend radiallymore outward than the proximal cuff 21, for example, the proximal cuff21 can structurally support the distal cuff 19 and provide a thickerlayer through which sutures can be stitched. The distal cuff 19 and theproximal cuffs 21 can form the shape of cylindrical discs with hollowcenters (i.e., where the attachment ring wall 29 and attachment ringchannel 14 are located). The distal cuff 19 can be on the distal side ofthe distal band 31, and the proximal cuff 21 can be on the proximal sideof the distal band 31 and attached to the distal band 31 and/or theattachment ring wall 29. The distal and proximal cuffs 21 can bestacked. The distal cuff 19 can be attached to the proximal cuff 21, forexample, at the radially outer circumference of the proximal cuff 21.

The cuffs 19 and/or 21 can each have a cuff pad 20 through which thesutures can be passed. The cuff pads 20 can be made from a mesh orfabric material that can be configured to allow penetration by a typicalsurgical needle and suture. The material of the cuff pad 20 can bestrong enough such that the cuff 19 and/or 21 can be secured by suturesagainst the epicardial wall without easily tearing should a small forcebe exerted on the attachment ring 22 by accidentally tugging theattachment ring 22 away from the epicardial wall. The cuff pads 20 canbe flexible. The cuff pads 20 can be configured to affix to suturespassed through the cuff pads 20.

The cuffs 19 and/or 21 can have cuff frames 23 that maintain the planarshape of the cuffs. The cuff frames 23 can also prevent the suture fromtearing through the cuff pad 20 and radially exiting and detaching fromthe cuff. The cuff frames 23 can be rigid circular bands attached to theexternal circumference of the cuff pads 20. The cuff frames 23 can bemetal and/or hard plastic. The suture can be passed through the cuff pad20 radially inside of the cuff frame 23.

The attachment ring wall 29 can have a ring wall interface lip 25 thatcan prevent the clamp 24 from shifting, slipping, or otherwise comingoff the attachment ring wall 29. The ring wall interface lip 25 canextend radially from the attachment ring wall 29 proximal from the cuffs19 and 21.

An integral or separately attached clamp 24 can be on the attachmentring wall 29 distal to ring wall interface lip 25 and proximal to thecuffs 19 and/or 21. The clamp 24 can apply an inward radial forceagainst the attachment ring wall 29. The clamp 24 can exert acompressive radially force around the attachment ring wall 29, forexample, to pressure-fit the inner surface of the attachment ring wall29 to the outer surface of an inflow conduit 10 when the inflow conduit10 is passed through the attachment ring channel 14. The compressiveforce from the clamp 24 can hold and seal the attachment ring 22 againstthe inflow conduit 10. The attachment ring seal 34 can prevent bloodflow from the heart from exiting between the attachment ring 22 and theinflow conduit 10. The inflow conduit 10 can separately seal around thecored hole in the epicardium. The clamp 24 can be on the radial outsideof the attachment ring wall 29 between the ring wall interface lip 25and the cuffs.

FIGS. 4a and 4b illustrate that the attachment ring 22 can have anattachment ring seal 34 at the proximal end of the attachment ring wall29. The attachment ring seal 34 can extend radially inward from theattachment ring wall 29 into the attachment ring channel 14. Theattachment ring seal 34 can be flexible. The attachment ring seal 34(and any other seals disclosed herein) can be made from a soft,resilient elastomer or other polymer. The attachment ring seal 34 can beintegral with or separate and attached to the attachment ring wall 29.The attachment ring seal 34 can produce a fluid-tight seal againstelements placed in the attachment ring channel 14, when the element inthe attachment ring channel 14 has an outer diameter larger than theinner diameter of the attachment ring seal 34.

The proximal band 26 can be inside of the ring wall interface lip 25.The ring wall interface lip 25 can extend radially outward from theattachment ring wall 29. The ring wall interface lip 25 can interferencefit against the clamp 24 to prevent the clamp 24 from translatingproximally off the attachment ring wall 29. The ring wall interface lip25 can be attached to and/or abutted against by an element adjacent tothe attachment ring 22. For example, the inflow conduit 10 can abutagainst the ring wall interface to prevent the inflow conduit 10 frompassing too far through the attachment ring channel 14. Also forexample, the valvular structure 12 can attach to the ring wall interfacelip 25. The proximal band 26 also provides structural support and ahemostatic seal when the attachment ring wall interface lip 25 andvalvular structure housing 18 are joined together.

The attachment ring 22 can have one cuff 35. The attachment ring wall 29can have a first distal band 32 on a distal side of the cuff 35 and asecond distal band 33 on a proximal side of the cuff 35. The cuff 35 canbe attached to, or pressure fit between, the first distal band 32 andthe second distal band 33.

FIG. 5 illustrates that the clamp 24 can be made of a single, continuouswire of material. The clamp 24 can be made from a metal and/or polymer(e.g., plastic). The clamp 24 can have a clamp frame 37 to transmit theradially compressive force and clamp handles 36 that can be used to openand/or close the clamp frame 37. The clamp frame 37 can be resilientlydeformable. The clamp frame 37 can have a clamp diameter 38. When theclamp 24 is in a substantially or completely relaxed or unbiasedconfiguration, the clamp diameter 38 can be smaller than the outerdiameter of the attachment ring wall 29 to which the clamp 24 attaches.

The clamp handles 36 can extend radially from the remainder of the clampframe 37. Compressive, squeezing force can be applied to the oppositeclamp handles 36 to move the clamp handles 36 toward each other. Thecompressive force applied to the clamp handles 36 can expand the clampdiameter 38, placing the clamp 24 in an open configuration.

When the clamp 24 is in an open configuration, the clamp 24 can beloaded onto and/or removed from the attachment ring 22. In the openconfiguration, an inflow conduit 10 can be passed through or retractedfrom the attachment ring channel 14.

FIGS. 6a and 6b illustrate another variation of the clamp 24. FIG. 6aillustrates the clamp 24 in an open configuration. The clamp 24 can havea frame made from a band of ribbon with a clamp handle 36 to loosen ortighten the clamp 24. The configuration as shown illustrates that afirst end of the clamp lever 39 is rotatably attached to a firstterminus of the clamp frame 37 and with the second end of the clamplever 39 rotatably attached to the clamp handle 36. The clamp handle 36can be rotatably attached to the second terminus of the clamp frame 37that is not attached to the clamp lever 39. The clamp handle 36 can beattached to the clamp frame 37 at a clamp hinge 40.

FIG. 6b illustrates the clamp 24 in a closed configuration. In thisillustration, the clamp handle 36 is rotated to cause the clamp frame 37to tighten the clamp frame 37 in the closed configuration. The clamphandle 36 can lie flush against the outer circumference of a length ofthe clamp frame 37. The clamp lever 39 can position a first terminus ofthe clamp frame 37 toward the second terminus of the clamp frame 37 whenthe clamp handle 36 is closed.

The clamp diameter 38 can be smaller when the handle is closed than whenthe handle is open. When the handle is closed, the clamp diameter 38 canbe smaller than the outer diameter of the attachment ring wall 29 towhich the clamp 24 attaches. When the handle is open (as shown in FIG.6a ), the clamp diameter 38 can be larger than the outer diameter of theattachment ring wall 29 to which the clamp 24 attaches. When the handleis open, the clamp diameter 38 can be larger than the outer diameter ofthe ring wall interface lip 25.

FIG. 7a illustrates that the clamp 24 can be on the attachment ring 22in an open configuration over the attachment ring external wall 29. Withthe clamp 24 in an open configuration, elements such as a coring knife,inflow conduit 10 or other surgical tools, can pass through theattachment ring channel 14. The clamp 24 can be against the outersurface of the attachment ring wall 29 between the ring wall interfacelip 25 and the cuff 35.

FIG. 7b illustrates that the clamp 24 can be in a closed configurationover the attachment ring external wall 29. With the clamp 24 in a closedconfiguration, the attachment ring wall 29 can compress onto and sealagainst elements placed in the attachment ring channel 14, such as theinflow conduit 10. The clamp 24 can be between the second distal band 33and the ring wall interface lip 25. The clamp 24 can exert a radiallyinward force against the attachment ring wall 29. The closed clamp 24can reduce the diameter of the attachment ring wall 29 and the diameterof the attachment ring channel 14.

FIGS. 8a through 8c illustrate that the inflow conduit 10 can beinserted into the attachment ring 22 to access the heart with the inflowconduit 10 and route blood through an inflow conduit channel 178 fromthe heart to the pump 8. The inflow conduit 10 can have an inflowconduit stop 42 configured to abut against or attach to other elements,for example, to preventing the inflow conduit 10 from over-insertionthrough the attachment ring 22. The inflow conduit 10 distal to theinflow conduit stop 42 can have an outer diameter smaller than the innerdiameter of the attachment ring channel 14. The inflow conduit stop 42can have an outer diameter larger than the inner diameter of theattachment ring channel 14.

The clamp 24 can be biased open (e.g., by compressing the clamp handles36 toward each other) when the inflow conduit 10 is inserted into theattachment ring channel 14, for example, to allow the inflow conduit 10to pass freely through the attachment ring channel 14. The clamp 24 canbe released and returned to a compressive state around the attachmentring wall 29 when the inflow conduit 10 is in a desired location withinthe attachment ring 22, for example, to clamp 24 the attachment ring 22onto the inflow conduit 10 and hold the inflow conduit 10 in place.

FIGS. 9a through 9c illustrate that the variation of the clamp 24 ofFIGS. 6a and 6b can be in an open configuration when the inflow conduit10 is inserted into the attachment ring channel 14, allowing the inflowconduit 10 to be inserted freely through the attachment ring 22. Theclamp handle 36 can be rotated open.

The inflow conduit 10 can be advanced through the attachment ringchannel 14 until the inflow conduit stop 42 abuts the proximal end ofthe attachment ring wall 29, for example at the ring wall interface lip25. The inflow conduit 10 can extend out of the distal end of theattachment ring 22, for example into and within fluid communication withthe chamber of the heart.

When the inflow conduit 10 is in a desired location within theattachment ring 22, the clamp 24 can be closed or released, for example,compressing the attachment ring wall 29 onto the inflow conduit 10. Theinflow conduit 10 can then pressure fit against the inner surface of theattachment ring wall 29, for example holding the inflow conduit 10 inplace relative to the attachment ring 22.

FIGS. 10a through 10e illustrate a variation of the valvular structure12 that can have a clamshell housing 18. The valvular structure 12 canhave a housing 18 with a housing first portion 46 separatably attachedto a housing second portion 54. The housing first portion 46 can have arotatable clamshell attachment to the housing second portion 54 and canbe rotated open and removed from the remainder of the ventricular assistsystem. In a closed configuration, the housing portions 46 and 54 candefine a housing channel 58 longitudinally through the housing 18 andopen on each end. The housing first portion 46 can attach to the housingsecond portion 54 at a housing first seam 51 and a housing second seam48. The housing first seam 51 can have a housing first joint 50. Thehousing second seam 48 can have a housing second joint 49.

The housing joints 49 and 50 can be pinned hinges. For example, thefirst and/or second housing joints 49 and/or 50 can have first and/orsecond joint pins 52 and/or 53, respectively. The housing portions 46and 54 can rotate about the housing joints 49 and 50. The respectivepins 52 and 53 can be removed from the housing joints 49 and 50 and thehousing portions 46 and 54 can be separated from each other at thehousing joint 49 and 50. After separation, the housing portions 46 and54 can be reassembled at the housing joints 49 and 50 and the joint pins52 and 53 can be reinserted into the housing joints 49 and 50. When thehousing 18 is separated at one or both joints 49 and 50, the valve 16,which is a discrete and separate element from the housing 18, can comeout of the housing 18 or otherwise be removed or detached from thehousing 18.

One or both of the housing portions 46 and 54 can have de-airing ports62. The de-airing ports 62 can be the ends of the de-airing channels 15.Air can be suctioned out of the de-airing ports 62 and/or saline orblood can be delivered from inside the housing 18 through the de-airingports 62 to remove the air from the volume between the valve 16 and theheart wall during the de-airing process.

The valve 16 can have first, second, third, and fourth valve leaflets56. The leaflets 56 can be flexible and resilient. The leaflets 56 canbe made from an elastomer. The valve 16 can have inter-leaflet seams 64between adjacent leaflets 56. Each leaflet 56 can have an intra-leafletfold 66. Each leaflet 56 can have a leaflet rib 57 or reinforcement onthe inter-leaflet seam 64 or intra-leaflet fold 66, for example toreinforce the leaflet 56 at the seam 64 or fold 66. The leaflets 56 canallow fluids and solids to move in the distal direction through thehousing channel 58. The leaflets 56 can oppose fluids and solids movingin the proximal direction through the housing channel 58. The leaflets56 can close against pressure from the distal side of the leaflets 56,for example, preventing the flow of blood from the heart out of thevalvular structure 12.

The valve 16 can have a valve seal 60 proximal to the leaflets 56. Thevalve seal 60 can extend radially into the housing channel 58. The valveseal 60 can be resilient. The valve seal 60 can seal against an element,such as the coring knife or inflow conduit 10, located in the housingchannel 58. When the leaflets 56 are spread open, the valve seal 60between the seal and the coring knife or inflow conduit 10 can preventthe flow of blood from the heart past the valve seal 60 and out of thevalvular structure 12.

The housing 18 can have a housing seal 47 distal to the valve 16. Thehousing seal 47 can seat in, and attach to the housing 18, via acircumferential housing seal groove 55 in the housing 18. The housingseal 47 can extend radially into the housing channel 58. The housingseal 47 can be resilient. Similar to the valve seal 60, the housing seal47 can seal against an element, such as the coring knife or inflowconduit 10, located in the housing channel 58. When the leaflets 56 arespread open, the seal between the housing seal 47 and the coring knifeor inflow conduit 10 can prevent the flow of blood from the heart outpast the housing seal 47.

The valve 16 can have a valve shoulder 59 that extends radially from thebase of the valve leaflets 56. The valve shoulder 59 can seat andinterference fit into a valve groove 61 recessed in the inner surface ofthe housing 18. The valve shoulder 59 can hold the valve 16 in the valvegroove 61.

FIGS. 11a through 11c illustrate another variation of the valvularstructure 12 that can have a latching closure configuration. The housing18 of this variation of the valvular structure 12 can latch closed, asshown in FIGS. 2a and 2b , locking the housing first portion 46 to thehousing second portion 54 in a closed configuration. The housing 18 canalso be opened by unlatching the housing first portion 46 to the housingsecond portion 54.

The housing 18 can have a first joint that can have a first joint latch69. The joint latch can be rotated open (as shown), decoupling thehousing first portion 46 and the housing second portion 54 at thehousing first seam 51. The first joint latch 69 can be rotated closed,laying substantially flush with the outer wall of the housing 18. In aclosed configuration, the first joint latch 69 can be closed onto andattach to a first joint catch 70. The first joint latch 69 can be on thehousing second portion 54, the first joint catch 70 can be on thehousing first portion 46.

When the housing first portion 46 is separated from the housing secondportion 54, the housing 18 can be removed from the valve 16. The valve16 is destructible and can be torn away from the ventricular assiststructure by hand or with a knife and removed from the target site afterthe housing 18 is removed. For example, after the inflow conduit 10 isinserted through the attachment ring 22 and the housing 18 is removed,the valve 16 can be torn away from the inflow conduit 10.

The housing first portion 46 and/or housing second portion 54 can eachhave coupling grooves 71 proximal to the valve 16. The coupling grooves71 can be configured to slidably and lockably interface with radiallyextending locking tabs 181 on other components that can interact withthe housing 18 such as the slitting blade case 158, coring knife, inflowconduit 10, or combinations thereof. The locking tabs 181 and couplegroove can interface to hold, fix, or otherwise releasably couple thecomponent inserted through the housing 18 to the housing 18 and to alignthe component inserted through the housing 18 to the housing 18. Forexample, the locking tabs 181 and coupling groove 71 can cause a slitfrom a slitting blade case 158 to be at the same angular orientation andposition as a coring abutment disc later-inserted through the slit, asshown in FIGS. 40b and 40 c.

FIGS. 12a through 15b illustrate variations of the valve 16 withdifferent configurations. FIGS. 12a and 12b illustrate that the valve 16shown in FIGS. 10a through 10e can be a four-leaflet valve 16. Theinter-leaflet seams 64 can extend radially from the center of the valve16 to the valve shoulder 59 with no inter-leaflet seam extending throughthe valve shoulder 59 or through the valve shoulder 59 to the outercircumference of the valve 16, or combinations thereof. For example, asshown in FIG. 12c , one of the inter-leaflet seams 64 can extend throughthe valve shoulder 59 while the remainder of the inter-leaflet seams 64can extend to the valve shoulder 59 without extending through the valveshoulder 59, and the one inter-leaflet seam 64 that extends through thevalve shoulder 59 can be aligned with one of the housing seams 51 or 48when loaded in the housing 18.

The inter-leaflet seams 64 can be completely separated seams,perforations, or combinations thereof along the length of the seam(e.g., complete separation between the leaflets 56 and perforation asthe seam extends through the valve shoulder 59). The valve 16 can betearable by hand, for example along the inter-leaflet seam 64. Forvalves 16 with a completely separated inter-leaflet seam 64, no tearingis necessary to separate the valve 16 from an element which the valve 16surrounds, such as the inflow conduit 10. As shown in FIG. 12c , thevalve can be rotated open, as shown by arrows, in a clamshellconfiguration to release the valve 16 from an inner element or componentwhich the valve 16 surrounds.

FIGS. 13a through 13c show another variation of the valve 16. The valve16 can be a quadcuspid (i.e., four-leaflet) valve that can haveinter-leaflet seams 64 that can extend through the valve shoulder 59 tothe outer circumference of the valve 16. FIG. 13c illustrates that thevalve 16 can be rotated open, as shown by arrows, at a firstinterleaflet seam 64 that extends through the valve shoulder 59 betweenthe first leaflet 68 and the second leaflet 65. The oppositeinter-leaflet seam 64 can extend to, but not through the valve shoulder59, acting as a hinge around which the valve halves can rotate. FIG. 13Dillustrates that the remaining inter-leaflet seams 64—other than theinter-leaflet seam 64 that extends through the valve shoulder 59 betweenthe first leaflet 68 and second leaflet 65—can extend to but not throughthe valve shoulder 59. The valve 16 can be further rotated open tospread open each inter-leaflet seam 64, for example when removing thevalve 16 from the coring tool or inflow conduit 10 placed through thevalve 16.

FIGS. 14a and 14b illustrate yet another variation of the valve 16 thatcan be a tricuspid valve (i.e., having three leaflets). FIGS. 15a and15b illustrate yet another variation of the valve 16 that can be abicuspid valve (i.e., having two leaflets).

FIGS. 15c through 15e illustrate variations of the valve 16 that canhave opposite inter-leaflet seams 64 that extend through the shoulder ona first side of the valve 16, and not through the shoulder on a secondside of the valve 16, opposite to the first side of the valve 16. Theopposite inter-leaflet seams 64 can converge in the middle of the valve16 to form a single slit along a diameter of the valve 16. The valves 16can be miter valves. The leaflets can join together at miters or bevelsat the inter-leaflet seams 64. The leaflets can pucker or duckbill atthe inter-leaflet seams 64.

FIG. 15c illustrates a quadcuspid valve 16. FIG. 15d illustrates abicuspid valve 16. FIG. 15e illustrates a unicuspid valve 16 (i.e.,having one leaflet) that can have a seam that does not extend to thevalve shoulder. A unicuspid valve is a type of diaphragm valve. Adiaphragm valve can have no more than one seam extending to theshoulder. The seam can be similar in length to the diaphragm seam 88shown in FIGS. 21a and 21 b.

FIG. 15f illustrates a diaphragm valve 16 that can have a diaphragm 82but no leaflets. The seam in the valve 16 can be a straight slit or port83 that can be closed in a relaxed an unbiased configuration. The slitor port 83 can extend along a diameter of the valve 16, but not extendto the valve shoulder 59. The valve 16 can duckbill, pucker or miteraround the port 83.

FIGS. 16a and 16b illustrate a variation of the valvular structure 12that can have a valve 16 that can be an inflatable membrane 73. Thevalve 16 can be inflated and deflated to close and open, respectively,the valve 16. The valve 16 can have an inflatable valvular chamber 75between the inflatable membrane 73 and the housing 18. The inflatablemembrane 73 can be resilient. The inflatable membrane 73 can be in adeflated and open configuration, as shown in FIG. 16 a.

FIG. 16b illustrates that the inflatable membrane 73 can be in aninflated and closed configuration. The inflatable valvular chamber 75can be pressurized, as shown by arrows, with a liquid (e.g., saline) orgas (e.g., carbon dioxide) to inflate the inflatable membrane 73. Theinflatable membrane 73 can seal around elements in the housing channel58, such as the coring knife or inflow conduit 10. The inflatablemembrane 73 can have a high-friction surface facing the housing channel58 that can pressure-fit against the coring knife or inflow conduit 10,fixing the coring knife or inflow conduit 10 in the housing channel 58.Alternatively, the inflatable membrane 73 can have a low-frictionsurface facing the housing channel 58 that can allow the coring knife ofinflow conduit 10 to slide within the housing channel 58 against theinflated inflatable membrane 73.

The pressure in the inflatable valvular chamber 75 can be released,returning the inflatable membrane 73 to the open configuration andreleasing the pressure-fit against any elements in the housing channel58.

FIG. 17a illustrates a variation of the valvular structure 12 that canhave a valve 16 that can be a torsioning or twisting membrane 77. Thetop and bottom of the housing 18 can be counter-rotated to open or closethe twisting membrane 77. The twisting membrane 77 can be loose andnon-resilient or taught and resilient and elastic. The housing firstportion 46 and second portion can each have a top rotatably attached toa bottom. The twisting membrane 77 can be attached to housing tops 78(the housing first potion top is shown) and bottoms 79 (the housingfirst potion bottom is shown) by a membrane anchor ring 76. The twistingmembrane 77 can be in an untwisted and open configuration, as shown.

FIG. 17b illustrates that the housing tops 78 can be rotated withrespect to the housing bottoms 79, as shown by arrows, for example, topartially or completely close the valve 16. The twisting membrane 77 cantwist upon itself and around elements in the housing channel 58. Thetwisting membrane 77 can be in a twisted and closed configuration. Thetops and bottoms can be counter-rotated to untwist and open the twistingmembrane 77.

FIGS. 18a and 18b illustrate another variation of the valve 16 that canbe a diaphragm valve that can be closed in an unbiased configuration andstretched open when the inflow conduit 10 or coring knife is pushedthrough the diaphragm valve. The valve 16 can have a first diaphragm 80and a second diaphragm 86. The diaphragms can be made from resilientmaterial, such as an elastomer, or combinations thereof. For example,the diaphragm can be made from silicone, polyurethane or other bloodcompatible polymers. The first diaphragm 80 can be in contact with andattached to the second diaphragm 86.

The first diaphragm 80 can have a first diaphragm port 81 that canreceive the inflow conduit 10 or coring knife. The second diaphragm 86can have a second diaphragm port 85 that can also receive the inflowconduit 10 or coring knife. The diaphragm ports can be circular. Thediaphragm ports can be resiliently expandable. For example, when a solidelement, such as the inflow conduit 10 or coring knife, with a diameterlarger than the diaphragm ports is forced through the diaphragm portsthe diaphragm ports can expand in shape and size to allow the solidelement to pass through the ports and can seal against the solidelement. When the solid element is removed from the diaphragm ports, thediaphragm ports can return to the relaxed, unbiased, shape and size ofthe diaphragm port.

The first diaphragm 80 can have a diaphragm interface lip 84. Thediaphragm interface lip 84 can be used to hold to diaphragm in the valvegroove 61 in the housing 18. The diaphragm interface lip 84 can be aring around the outer circumference of the first diaphragm 80 that canbe raised or thickened compared to the remainder of the first diaphragm80. The diaphragm interface lip 84 can be formed a result of theattachment of the second diaphragm 86 and the first diaphragm 80. Forexample the diaphragm interface lip 84 can be a rib formed by fusing,gluing or welding, or a reinforcement.

The second diaphragm 86 can have a diameter smaller than the diameter ofthe first diaphragm 80. The second diaphragm 86 can be attached to thefirst diaphragm 80 at or near the outer circumference of the seconddiaphragm 86. The second diaphragm 86 can attach to the first diaphragm80 on the diaphragm interface lip 84 or on the face of the firstdiaphragm 80 on the opposite side of the diaphragm interface lip 84.

When the first diaphragm 80 and the second diaphragm 86 are attached,the first diaphragm port 81 can be incongruous from (i.e., notoverlapping with) the second diaphragm port 85 when the first and seconddiaphragms 80 and 86 are in relaxed, unbiased configurations. When thediaphragm valve 16 is in a relaxed, unbiased configuration, the firstdiaphragm port 81 and the second diaphragm port 85 can overlapcompletely, partially or not at all (as shown). The diaphragm valve 16can have a substantially fluid-tight seal in a relaxed configuration.

The diaphragm valve 16, or other valve variations such as the leafletvalves, can allow a check flow, for example a small amount of blood flowused to test or confirm if positive blood pressure exists on theopposite side of the valve 16. For example, the pressure between thefirst diaphragm 80 and the second diaphragm 86 can be insufficient tocompletely seal when pressurized blood from the heart is in contact withthe diaphragm valve 16, and a small trickle or drip-flow of blood canpass through the diaphragm ports 81 and 85. In an alternative variation,the leaflets can have a check flow channel, a small channellongitudinally aligned in the inter-leaflet seam that can allow checkflow to flow between adjacent leaflets in a direction opposite to thelow-resistance orientation of valve.

FIGS. 19a and 19b illustrate a variation of the attachment ring 22 withan integrated diaphragm valve 16. The first diaphragm 80 can be integralwith the attachment ring wall 29. The first diaphragm 80 cansubstantially close the end of the of the attachment ring channel 14.The second diaphragm 86 can be attached to the first diaphragm 80 and/orthe attachment ring wall 29. Similarly, the other valve types describedcan also be integrated with the attachment ring 22. For example, FIGS.19c and 19d illustrates a variation of the attachment ring 22 integratedwith a quadcuspid valve 16. FIG. 20 illustrates the exploded assembly ofa variation of the diaphragm valve 16 in a valvular structure 12attached to an attachment ring 22. The valve 16 can be separate anddetachable from the attachment ring 22. The diaphragm 82 can be attachedto a diaphragm flap 87. The housing first portion 46 and housing secondportion 54 can have a diaphragm groove 90 circumferentially around theradially inner surface of the housing 18. The diaphragm interface lip 84can seat in and attach to the diaphragm groove 90.

The housing first portion 46 and housing second portion 54 can have aring groove 94 circumferentially around the radially inner surface ofthe housing 18. The ring wall interface lip 25 can seat in and attach tothe ring groove 94.

The housing first portion 46 can have a housing first handle 93. Thehousing second portion 54 can have a housing second handle 91. Thehousing handles 91 and 93 can be pulled to separate the housing firstportion 46 from the housing second portion 54. For example, the housingfirst seam 51 and the housing second seam 48 can be completely separatedor perforated.

The tape 89 can be a substantially unresilient, flexible polymer striptightly wrapped around the radial outer surface of the housing 18. Thetape 89 can radially compress the housing first portion 46 and thehousing second portion 54, keeping the housing first portion 46 attachedto the housing second portion 54. The tape 89 can have an adhesiveapplied to the radial inner surface. The tape 89 can be wound once ormore around the housing 18 and can stick to the housing 18 and to innerlayers of the tape 89 itself.

Alternatively, the tape 89 can be an elastomeric hollow cylinder orband. The tape 89 can be placed onto the housing 18 by stretching thetape 89 over the housing 18 and releasing the tape 89 from thestretching force, resiliently radially compressing the housing 18.

FIGS. 21a through 21c illustrate another variation of the diaphragmvalve 16. FIG. 21 b illustrates that the diaphragm 82 can have adiaphragm seam 88 extending from the diaphragm port 83 to the externalcircumference of the diaphragm 82. The diaphragm seam 88 can be acomplete split separating each side of the diaphragm seam 88, allowingan element, such as the inflow conduit 10 or coring knife, to passthrough the diaphragm 82 at the diaphragm port 83 and/or the diaphragmseam 88. The diaphragm port 83 can be in the radial center of thediaphragm 82. The diaphragm flap 87 can cover the diaphragm port 83.

FIG. 21c illustrates that the diaphragm flap 87 can attach to thediaphragm 82 at an attachment area 96. The diaphragm flap 87 can beunattached to the diaphragm 82 except for at the attachment area 96,allowing the diaphragm flap 87 to open out of the way when an element ispushed through the diaphragm port 83 and/or diaphragm seam 88. Thediaphragm flap 87 can be rigid or flexible. The diaphragm flap 87 can beresilient. The diaphragm flap 87 can be made from the same materials asthe diaphragm 82.

The diaphragm flap 87 can extend to the external circumference. Thediaphragm flap 87 can cover the diaphragm port 83 and the diaphragm seam88. The diaphragm flap 87 can cover a portion of the side of thediaphragm 82 and leave a portion of the side of the diaphragm 82 exposed(as shown) or can cover the entire side of the diaphragm 82.

When the fluid pressure on the side of the diaphragm 82 of the diaphragmflap 87 exceeds the fluid pressure on the side of the diaphragm 82opposite the diaphragm flap 87, the diaphragm flap 87 can press againstthe diaphragm seam 88 and diaphragm port 83, further sealing thediaphragm 82.

When an element, such as the coring knife or inflow conduit 10, isforced through the diaphragm 82 from the side of the diaphragm 82opposite of the diaphragm flap 87, the element can press open thediaphragm 82 at the diaphragm port 83 and diaphragm seam 88, and thediaphragm flap 87 can be pressed aside as the element moves through thediaphragm 82.

FIG. 22 illustrates that when the valvular structure 12 is assembled thediaphragm interface lip 84 can be seated in the diaphragm groove 90 ofthe housing 18. The housing first portion (not shown) and the housingsecond portion 54 can be compressed together by tape 89 wound around theexternal circumference of the housing 18.

FIG. 23 illustrates that the valvular structure 12 can have a lockingring 98 that can be used to compress the attachment ring 22 against aninflow conduit 10 placed in the attachment ring channel 14. For example,the locking ring 98 can be used in lieu of or in addition to the clamp24. The locking ring 98 can be releasably attached to the radiallyinternal surface of the housing 18. The locking ring 98 can be separablyattached to the housing 18 with circumferential rails and interfacinggrooves on the radially outer surface of the locking ring 98 and theradially inner surface of the housing 18.

The de-airing ports 62 (as shown) can act as handle ports and/or be usedto de-air the valvular structure 12. The handle ports can attach tohousing handles or can be open to be used for de-airing, as describedherein.

FIG. 24 illustrates that the tape 89 can be wound radially around theouter surface of the housing 18. The tape 89 can compress the housingfirst portion 46 to the housing second portion 54. The tape 89 can haveadhesive, for example, on the side of the tape 89 facing the housing 18.The tape 89 can have no adhesive and be elastic, for example, attachingto the outer surface of the housing 18 by a friction-fit from the tape89 elastically compressing against the housing 18.

FIG. 25 illustrates that the valvular structure 12 can be attached tothe attachment ring 22, for example, by snapping the valvular structure12 onto the attachment ring 22. The valvular structure 12 can beattached to the attachment ring 22 before or during the VAD implantprocedure.

The valvular structure 12 can be translated, as shown by arrow, over theattachment ring wall 29. The ring wall interface lip 25 can have asloped side facing in the direction of the on-loading valvular structure12. As the valvular structure 12 is being pressed onto the attachmentring 22, the portion of the housing 18 that is distal to the ring groove94 can deform over the sloped side of the ring wall interface lip 25.The ring wall interface lip 25 can then seat and interference fit intothe ring groove 94.

FIGS. 26a and 26b illustrate another variation of snapping the valvularstructure 12 onto the attachment ring 22. In this variation, thevalvular structure 12 can have a locking ring 98. The locking ring 98can have a locking ring wall angle 100 with respect to the housingchannel longitudinal axis 103. The locking ring wall angle 100 can be,for example, from about 3° to about 15°, for example about 10°.

The ring wall interface lip 25 can have a sloped side facing in thedirection of the on-loading valvular structure 12. The sloped side ofthe ring wall interface lip 25 can form a ring wall angle 102 with theattachment ring channel longitudinal axis 101. The ring wall angle 102can be from about 3° to about 15°, for example about 10°. The ring wallangle 102 can be substantially equal to the locking ring wall angle 100.

The valvular structure 12 can be pressed onto the attachment ring 22,over the attachment ring wall 29, as shown by arrow. As the valvularstructure 12 is being pressed onto the attachment ring 22, the portionof the housing 18 distal to the ring groove 94 can deform over thesloped side of the ring wall interface lip 25.

FIG. 26b illustrates that the valvular structure 12 can be pressed ontothe assembly ring, as shown. The ring wall interface lip 25 can seat andinterference fit into the ring groove 94.

Method of Using

FIGS. 27a and 27b illustrate a process for surgically implanting aventricular assist system. It should be appreciated to a person withordinary skills in the art that the surgical, preparation, andimplantation processes described can be performed in a different orderas presented. The surgical process for implanting the ventricular assistsystem can begin by anesthetizing the patient and placing the patient ina supine position. The left ventricular apex and ascending aorta 104 canthen be exposed using a less invasive approach, such as a left subcostalincision and a second right anterior mini-thoracotomy, or a commonsternotomy which is typically more invasive but allows more space for asurgeon to operate.

The method can include space for placement of an outflow conduit 2/graftby tunneling from a subcostal position to an aortic location. Forexample, an outflow graft tunnel can be created between the twoincisions (e.g., the left subcostal incision and the right anteriormini-thoracotomy) with a malleable tunneler and/or a curved tunneler.The tunneler 177 can begin at the left subcostal thoracotomy and tunnelto the right anterior mini-thoracotomy.

The tunneler 177 can have a tunneler tip that can then be removed fromthe tunneler once the tunneler has reached the right anteriormini-thoracotomy. The outflow graft connector can then be attached tothe end of the tunneler and pulled back through the tunnel createdbetween the incisions. The outflow graft can then be connected to a pumpsizer at the target site for the pump 8. The pump sizer is a plasticelement the size and shape or the pump 8 that can be used to check thefit of the finally deployed pump 8 by inserting the pump sizer at thetarget site before inserting the pump 8.

With the outflow graft attached to the pump sizer, the outflow graft canbe measured and cut to length to fit the space between the pump 8 andthe aorta 104 with enough slack in the outflow conduit 2 to allowmovement of the pump 8 and organs, but not too much slack to enablekinking of the outflow conduit 2.

If the process does not include the use of a heart-lung by-pass machineand is performed while the heart 106 is pumping, the outflow graft canthen be anastomosed to the aorta 104 using a side biting clamp to holdthe aorta 104 and an aortic punch 126 to make the incision in the aorta104.

After blood is allowed to flow into the outflow graft for purging airfrom inside the outflow graft or conduit 2, a clamp 131, such as ahemostat, can then be placed on the outflow graft 2, or a balloon 135can be inflated in the outflow graft to stanch the flow of blood fromthe aorta 104 through the outflow graft 2. The control of blood from theheart 106 and de-airing can also or additionally be performed bycreating a slit into the wall of the outflow graft 2. A balloon catheter132 can then be delivered into the outflow graft 2 through the slit. Theballoon 135 can then be positioned in the pump outflow connector andinflated to plug the pump outflow connector. End and or side ports onthe balloon catheter 132 can be used for de-airing.

The pump 8 and the inflow conduit 10 or inflow graft can be preparedprior to connection of the inflow conduit 10 to the heart 106. Theproximal end of the inflow conduit 10 is connected to the pump 8 in asaline bath to purge all air from the inflow conduit 10 and the pump 8prior to having the distal end of the inflow conduit 10 connected to theheart 106. In this preparation process, the entire inflow conduit 10 andthe pump 8 can both be submerged into a saline bath and connected. Ablockage at the outflow end of the pump 8 is placed to prevent bloodfrom escaping after the distal end of the inflow conduit 10 is connectedto the heart 106.

Prior to connection of the inflow conduit 10 to the heart 106, theattachment ring 22 can be sewed onto the epicardial surface of thetarget connection area on the heart 106. In one variation, sutures canbe used to secure the cuff 35 of the attachment ring 22 onto the heart106. The valvular structure 12 or external seal can then be securedagainst the attachment ring 22, for example, by placing and securing thevalvular structure 12 over the walls forming the attachment ring channel14. A slitting blade or tool can be inserted through the valvularstructure 12 and the attachment ring 22 to create a slit into themyocardium at the target connection area. A coring knife 140 can then beinserted through the slit and used to core a portion of the myocardium.The inflow conduit 10 can then be inserted through the valvularstructure 12 and the attachment ring 22 to into the opening of the heart106 created by the coring knife. The inflow conduit 10 can be secured tothe attachment ring 22 with the radial clamp 24. The valvular structure12 including the external seal can then be removed. The inflow conduit10 can be inserted further into the left ventricle. The radial clamp 24can then be radially compressed (e.g., released from a radially expandedconfiguration) and/or locked to secure the inflow conduit 10 to theattachment ring 22.

The entire system can be completely de-aired in the process ofconnecting the outflow graft to the pump 8. De-airing or the removal ofall the air from the outflow graft and the pump 8 can be performed withthe use of a de-airing bladder, enclosure or a bath of saline. Theunconnected end of the outflow graft can be submerged into the bath ofsaline along with the outflow end of the pump 8 that has the blockage.The clamp or balloon 135 can be removed from the outflow graft and allthe air in the outflow graft and pump 8 can be allowed to escape orpushed by the flow of blood from the aorta 104 into the bladder,enclosure, or the bath of saline, for de-airing. Similarly, the outflowend of the pump 8 with the blockage is also submerged into the salinebath. Once the hemostatic outflow graft clamp 131 is removed from theoutflow graft and the blockage is removed from the outflow end of thepump 8, any air remaining in either the outflow graft or in the pump 8will be allowed to escape into the saline bath or enclosure. If theballoon 135 had previously been inserted into the pump outflowconnector, the de-airing can occur by releasing the hemostatic clamp 131from the outflow graft 2 resulting in blood from the aorta 104 floodingand bleeding out the outflow graft 2. The outflow graft 2 can then beconnected to the pump outflow connector. The balloon 135 can be deflatedand the balloon catheter 132 can then be pulled out from outflow graft2. The hole in the site of the outflow graft 2 used for introducing theballoon catheter 132 can then be closed with a purse string suture. Theoutflow graft 2 is connected to the outflow end of the pump 8 after airis removed from the system.

A tunnel can be formed for the percutaneous lead 5 to extend from thepump 8 out of the body. The pump 8 can then be turned on to run andassist the blood flow from the left ventricle. The surgical wounds onthe patient can then be closed.

FIGS. 28 to 35 will collectively illustrate the process of accessing theheart 106 and target implantation vasculature and the tools used tocreate a tunnel for an outflow conduit 2. FIGS. 28, 32 and 35 illustratethe process of creating a tunnel and implanting an outflow conduit 2 inthe tunnel, and FIGS. 29a through 31 illustrate the variations of toolsused for this tunnel creation process. FIGS. 33a through 33c illustratethe process and tools for creating an aortotomy 128 in the targetvasculature for an anastomotic connection with the outflow conduit 2.FIGS. 34a through 34b illustrate the processes and tools for preventingblood from spilling out of the outflow conduit 2 after it is connectedto the target vasculature.

FIG. 28a illustrates the creation of a tunnel for the outflow conduit 2without a sternotomy. FIG. 28b illustrates that when a sternotomy isperformed, creating a sternotomy opening 107, there is no need totunnel.

In a less invasive variation of the procedure, as shown in FIG. 28a ,the target site can be accessed by making a first incision 110 caudallyor inferior to the target site, for example just below the apex on theleft side of the heart 106. A second incision 108 can be made cranial tothe target site, on an opposite side of the target site from the firstincision 110. The second incision 108 can be made near the right secondintercostal to provide access to the aorta 104. The tunneler 177 canthen be inserted, as shown by arrow 111, into the first incision 110 andtunneled between the first and second incision 110 and 108, as shown byarrow 109. The end of the tunneler 177 can then exit, as shown by arrow105, from the patient at the second incision 108, or be inside thepatient but accessible from the second incision 108.

FIGS. 29a to 30b illustrate variations of a tunneler 177 that can beused for creating the outflow conduit tunnel FIG. 29a illustrates oneexample of a tunneler 177 that can have an elongated tunneler shaft 115.The tunneler 177 can have a tunneler handle 114 at a proximal end of thetunneler shaft 115. The tunneler shaft 115 can be straight when in atorsionally unstressed state. The tunneler shaft 115 is of asubstantially smaller diameter than the distal attachment cone 118 sothat it can be malleable or flexible for shaping into a configurationthat fits the anatomy of the patient. The tunneler 177 can have a distalattachment cone 118 at the distal end of the tunneler shaft 115. In onevariation, this distal attachment can be a bullet tip 124 at the distalend of the tunneler 177. The bullet tip 124 can have a smooth or flushseam with the distal attachment cone 118. The bullet tip 124 can beremoved from the distal attachment cone 118 and expose or be replacedwith different distal attachment interface configurations. For example,the bullet tip 124 can be attached to, or replaced with, a distalattachment collet 123 extending distally from the distal attachment cone118, as shown in FIG. 29b . Similarly, the bullet tip 124 can beattached to, or replaced with, a distal attachment bolt 122 extendingdistally from the distal attachment cone 118, as shown in FIG. 29c . Thedistal attachment bolt 122 can have helical thread 121. The objective ofthe distal attachment bolt 122 and the distal attachment collet 123 arefor attachment with a proximal end of the outflow graft as will beillustrated further below.

FIGS. 30a and 30b illustrate another variation of the tunneler 177 thatcan have an outer sheath 125 attached to the distal attachment cone 118.The tunneler shaft 115 can be separate from the outer sheath 125 anddistal attachment cone 118. The outer sheath 125 can be of a diameterthat is similar to the diameter of the distal attachment cone 118 andcan be hollow. While the diameter of the tunneler shaft 115 and theouter sheath 125 differs, the outer sheath 125 and the tunneler shaft115 can have substantially equal radii of curvature. The tunneler shaft115 and outer sheath 125 can be rigid. The tunneler shaft 115 can beslidably received by the outer sheath 125.

The tunneler 177 can be inserted through the first incision 110 at adesired location in the abdomen and/or thorax to create the tunnel forultimate placement of the outflow conduit 2. The bullet tip 124 can beconfigured with a blunt tip to atraumatically separate or create a paththrough tissue when the tunneler 177 is being inserted through thepatient.

FIG. 31 illustrates that the bullet tip 124 can be removed and theoutflow conduit coupler 4 can be attached to the distal attachmentinterface. The outflow conduit 2 can extend from the terminus of thetunneler 177. The tunneler 177 can be used to manipulate the locationand orientation (i.e., rotate, twist, translate, steer) of the outflowconduit 2.

The outflow conduit 2 can be attached to the tunneler 177 after thedistal end of the tunneler 177 is passed through the patient and out of,or adjacent to, the second incision site, such as a surgical openingnear the aorta 104 like a right anterior mini thoracotomy or a ministernotomy near the aorta 104. FIG. 32 illustrates that when the distalattachment interface is positioned at the distal end of the tunnel orout of the second incision 108, the bullet tip 124 can be removed fromthe distal attachment interface and the outflow conduit coupler 4 can beattached to the distal attachment interface. The tunneler handle 114 canthen be pulled to draw the outflow conduit coupler 4 and outflow conduit2 through the tunnel.

FIG. 33a illustrates the use of an aortic clamp 127 to clamp a portionof the wall of the aorta 104. This aortic clamp 127 can be a side-bitingclamp of any shape, and is typically used when the vasculature (e.g.,aorta 104) is still filled with blood, for example, when a heart-lungby-pass machine is not used. An aortic punch 126, or scalpel or othertool can be applied to the clamped portion of the aorta 104 to create asmall opening in the vasculature or target vessel (e.g., aorta 104), asshown in FIG. 33b . FIG. 33c illustrates that the outflow conduit 2 canthen be attached to the target vessel by attaching the circumferentialedge of the distal end of the outflow graft/conduit around the openingwith sutures (as shown), staples, clips, brads, glue, or combinationsthereof.

FIG. 34a illustrates removal of the aortic clamp 127 from the aorta 104.Once the aortic clamp 127 is removed, blood flow 130 through the aorta104 will branch off and flow through the outflow conduit 2, as shown byarrows. If the outflow conduit 2 is not obstructed, the blood flow 130from the aorta 104 can flow through the outflow conduit 2 and exitthrough the (proximal) open end of the outflow conduit 2.

FIG. 34b illustrates a variation of a method for stanching the bloodflow 130 through the outflow conduit 2. A vascular clamp 131 can beplaced on the outflow conduit 2 to compress the outflow conduit 2,closing and obstructing the outflow conduit 2 and stanching the flow ofblood from the aorta 104 through the outflow conduit 2.

FIG. 34c illustrates another variation of a method for stanching bloodflow 130 through the outflow conduit 2. An inflatable balloon 135,similar to an angioplasty balloon, can be inserted through the wall ofthe outflow conduit 2. The balloon 135 can be in fluid communicationwith a catheter 132. The balloon 135 can be inflated with a gas (e.g.,carbon dioxide) or liquid (e.g., saline.) The balloon 135 can beinflated when in the outflow conduit 2, closing the outflow conduit 2and stanching the flow of blood from the aorta 104 through the outflowconduit 2. The balloon 135 can be made of a single material along theentire surface of the balloon 135.

FIG. 34d illustrates yet another variation of a method for stanchingblood flow 130 through the outflow conduit 2. The balloon 135 can becovered with two or more materials. In a first variation, the balloon135 can be a composite balloon made of two sub-balloons, the firstsub-balloon covered with a first material and having a first volume, andthe second sub-balloon covered with the second material and having asecond volume. In a second variation, the balloon 135 cave have a firstvolume covered by the first material and separated by a balloon septum185 from the second volume covered in the second material. The firstvolume can be in fluid communication with a first channel in thecatheter 132, and the second volume can be in fluid communication with asecond channel in the catheter 132 or a second catheter. The firstmaterial can be on the balloon distal surface 133 and the secondmaterial can be on the balloon proximal surface 134. The first materialon the balloon distal surface 133 can be gas impermeable. The secondmaterial on the balloon proximal surface 134 can be made from a materialthat can be gas permeable, but not liquid permeable (i.e., a breathablemembrane such as PTFE or acrylic copolymer). The balloon distal surface133 can face the aorta 104 and the balloon proximal surface 134 can faceaway from the aorta 104 when the balloon 135 is inserted in the outflowconduit 2 and inflated.

When de-airing the outflow conduit 2, fluid (e.g., blood and residualair) can be pumped from the pump 8 through the outflow conduit coupler4. Air in the VAD can pass through the balloon proximal surface 134 andinto the balloon 135. The balloon distal surface 133 and first volumecan be inflated to obstruct the air from flowing through the vessel andforce the air into the balloon proximal surface 134 while allowing theblood and/or saline to flow through the outflow conduit 2 and into theaorta 104. The air captured in the balloon 135 can be withdrawn throughthe catheter 132.

FIG. 35 illustrates that the outflow conduit 2 can be drawn through thetunnel, for example, positioning the outflow conduit coupler 4 near thefirst incision 110 or otherwise at or adjacent to the target site forthe pump 8. As described above, the outflow conduit 2 can be connectedto the aorta 104 (i.e., aortic anastomosis) with an aortic attachmentdevice, such as aortic sutures 117. The aortic anastomosis can occurbefore or after the outflow conduit 2 is drawn into and/or through thethorax, for example, by the tunneler 177.

After the outflow conduit 2 is drawn through the thorax, the attachmentring 22 can be sutured to the heart apex 119 with an apical attachmentdevice, such as apical sutures 113. The attachment ring 22 can be placedagainst, and attached to, either the left (e.g., at the apex) or rightventricles or the left or right atria. The apical sutures 113 can be thesame or different suture material and size as the aortic sutures 117.The attachment ring 22 can be attached to the apex with or without thevalvular structure 12 attached to the attachment ring 22.

FIGS. 36a through 38 illustrate variations of a cutting tool, such asthe coring knife 140, that can be used to core a piece of the epicardialtissue while the heart 106 is beating. FIGS. 36a through 36e illustratea variation of the coring knife 140 with a cylindrical coring blade 137configured to chop or shear heart tissue against an abutment surface onthe proximal side of a conical knife head 136. FIGS. 37a through 37dillustrate another variation of the coring knife 140 that can have arotatable coring abutment 145 to insert through a small slit in theheart 106 and then rotate to squeeze against and compress the hearttissue which is desired to be cored. FIG. 38 illustrates a yet anothervariation of the coring knife 140 that has a foreblade 152 that isindependently deployable from the knife head 136.

FIGS. 36a through 36d illustrate a variation of the coring knife 140.The coring knife 140 can have a hollow cylindrical coring blade 137. Thecoring knife 140 can have a conical or bullet-shaped knife head 136. Theknife head 136 can be shaped to push apart a pre-cut slit in epicardialtissue to introduce the knife head 136 into the left ventricle. Theproximal surface of the knife head 136 can be a coring abutment 145 thatthe coring blade 137 can cut against.

The coring knife 140 can have a knife handle 139 at the proximal end ofthe coring knife 140. The knife handle 139 can be fixed to a coringcontrol shaft 143. The coring control shaft 143 can be fixed to theknife head 136. Translation of the knife handle 139 can directly controltranslation of the knife head 136. The knife can have a knife stop 138radially extending from the body of the coring knife 140. The knife stop138 can limit the extent of the translation of the knife handle 139, andtherefore the knife head 136, with respect to the coring blade 137. Theknife stop 138 can prevent over insertion of the coring blade 137 intotissue. For example, in use the knife stop 138 can abut the attachmentring 22 or valvular structure housing 18 preventing or minimizing therisk of inserting the coring blade 137 through the heart wall and intothe septum.

FIG. 36e illustrates that the knife handle 139 can be translateddistally, as shown by arrow, to translate the knife head 136 distally(i.e., extend), as shown by arrow, away from the coring blade 137. Theknife handle 139 can be translated proximally, as shown by arrow, totranslate the knife head 136 proximally (i.e., retract), as shown byarrow, toward the coring blade 137. The coring abutment 145 caninterference fit against the distal cutting edge of the coring blade137. The coring abutment 145 can move within and adjacent to the coringblade 137, for example when the outer diameter of the coring abutment145 is smaller than the inner diameter of the distal end of the coringblade 137. In this configuration, the coring abutment 145 can sheartissue against the coring blade 137.

FIGS. 37a and 37b illustrate a variation of the coring knife 140 thatcan have a rotatable coring abutment 145 that can be passed through aslit in the heart wall and then rotated to face the coring blade 137.The coring abutment 145 can be a circular disc. If the slit in the heartwall is not already created when the coring abutment 145 is passedthrough the heart wall and/or the slit is not large enough for thecoring abutment 145 to pass, the circular disc of the coring abutment145 can be used to create the slit in the heart wall. The coringabutment 145 can be rotatably attached to a control arm 146. The controlarm 146 can be attached to the knife handle 139 in a configurationallowing the knife handle 139 to rotate the coring abutment 145 throughmanipulation of the control arm 146. The knife handle 139 can berotatably attached to the proximal end of the coring control shaft 143.

The outside surface of the coring control shaft 143 can have a helicalcoring groove, for example along the length of the coring control shaft143 that passes through the coring knife case 141. The coring knife case141 can have a guide peg 148 that extends radially inward from thecoring knife case 141. The guide peg 148 can be fixed to the coringknife case 141. The guide peg 148 can seat in the helical coring groove,controlling the movement of the coring control shaft 143 with respect tothe coring knife case 141. For example, the coring blade 137 can berotated helically with respect to the coring knife case 141.

FIG. 37c illustrates that the knife handle 139 can be rotated, as shownby arrow 142, rotating the coring abutment 145, as shown by arrow 149.The plane defined by the coring abutment 145 in a rotated configurationcan be parallel to the plane defined by the cutting edge of the coringblade 137.

FIG. 37d illustrates that the knife handle 139 can be moved in a helicalmotion, as shown by arrow 144, helically moving the coring control shaft143 and coring blade 137, as shown by arrow 150. The helical motion ofthe knife handle 139 can be constrained by the guide peg 148 slidablyfitting into the helical coring guide 147. The coring blade 137 can behelically rotated and translated to abut the proximal surface of thecoring abutment 145. The coring blade 137 can be rotated and translateduntil the coring blade 137 abuts the coring abutment 145.

FIG. 38 illustrates that the coring knife 140 can have a foreblade 152that can be used to create a slit in the epicardial tissue through whichthe coring knife 140 can be inserted into the ventricle. The coringknife 140 with a rotatable coring abutment 145 can also be configuredwith an integral foreblade 152. The foreblade 152 can be controllablyextended distally out of the distal surface of the knife head 136. Thecoring knife 140 can have a foreblade control knob 155 that can be usedto extend and retract the foreblade 152. The foreblade control knob 155can be fixed to the foreblade 152 by a foreblade control shaft 174,shown in FIGS. 41b through 41d . The foreblade control knob 155 can betranslated proximally and distally, as shown by arrows 154, within aknob port 157 to translate the foreblade 152 proximally and distally,respectively, as shown by arrows 153, with respect to the knife head136.

Translating the knife handle 139, as shown by arrows 162, can translatethe knife head 136, as shown by arrows 151, independently of theforeblade 152. Translating the knife handle 139 can extend and retractthe coring blade 137. The foreblade control knob 155 can be rotated,shown by arrows 156, to lock or unlock the translation of the foreblade152 to the translation of the knife handle 139.

The knife head 136 can have a chisel-tipped configuration. The distalend of the knife head 136 can be traumatic or atraumatic.

FIGS. 39a and 39b illustrate that the coring knife 140 can be inserted,as shown by arrow, through the housing 18 of the valvular structure 12and the attachment ring 22. The leaflets 56 of the valve 16 canresiliently deform away from the coring knife 140. The leaflets 56,valve seal 60, housing seal 47, or combinations thereof, can formfluid-tight seals around the coring knife 140, for example to prevent orminimize the flow of blood from the heart 106 and out of the valvularstructure 12 during use of the coring knife 140.

FIGS. 40a through 40i illustrate a variation of a method for coring theheart 106 and attaching the inflow conduit 10 to the heart 106 while theheart 106 is beating. FIG. 40a illustrates that the attachment ring 22can be placed against the wall of the heart 106. One or more sutures 113can be sewn through the cuff 35 and the heart 106, fixing the attachmentring 22 to the heart 106. The clamp 24 can be attached to the attachmentring 22 in an open configuration, as shown. The valvular structure 12can be attached to the attachment ring 22 before or after the attachmentring 22 is attached to the heart 106. The air can be removed from theattachment ring channel 14 and/or housing channel 58 at any time byinserting blood and/or saline into the de-airing port 62 and/or byapplying suction to the de-airing port 62, for example before slittingor coring an opening into the heart wall.

FIG. 40b illustrates that the initial slit in the heart wall can be madeby a slitting blade. The slitting blade can be contained in a slittingblade case 158 and configured to extend from and retract into theslitting blade case 158. The slitting blade case 158 can be insertedthrough the valvular structure 12 and attachment ring 22. The slittingblade case 158 can have slitting blade handles 160 and a slitting bladeplunger 159. The slitting blade plunger 159 can control a sharp, linearslitting blade (not shown) at the distal end of the slitting blade case158. The slitting blade plunger 159 can be translated, as shown by arrow161, inserting the slitting blade through the heart 106 and forming aslit in the heart 106. The valve 16 and seals in the valvular structure12 can form a fluid-tight seal against the slitting blade case 158,preventing blood from flowing out of the heart 106 through the valvularstructure 12. The slitting blade case 158 can be removed from thevalvular structure 12 and the procedure site after the slit is formed.Instead of a slitting blade, the slit can be formed by a foreblade 152extended from a coring knife 140, as shown and described in FIGS. 41athrough 41 d.

FIG. 40c illustrates that the coring knife 140 can be translated, asshown by arrow 163, into the valvular structure 12 and attachment ring22. The coring knife 140 engages with the valvular structure 12 withlocking tabs 181 and locking slots or coupling grooves 71 to provide areliable connection and a depth marker and locator. The coring abutment145 can be inserted through the slit in the heart 106 formed by theslitting blade. The coring abutment 145 can be pushed into the leftventricle 165 while the heart 106 continues to beat. The seals and valve16 can produce a seal around the coring knife 140 preventing blood fromflowing out of the beating heart 106 through the valvular structure 12.

FIG. 40d illustrates that the knife handle 139 can be rotated, as shownby arrow 142, rotating the coring abutment 145, as shown by arrow 149,for example, to prepare the coring knife 140 to core a portion of theheart 106. The coring abutment 145 can be in a plane substantiallyparallel with, and adjacent to, the internal side of the adjacent heartwall in the left ventricle 165.

FIG. 40e illustrates twisting the coring blade 137 to cut a cylinder ofthe heart wall away from the rest of the heart wall. The handle can behelically moved, as shown by arrow 144, helically extending the coringblade 137, as shown by arrow 150, through the heart wall. The distaledge of the coring blade 137 can be sharpened and/or serrated and cancut the heart wall as the coring blade 137 moves through the heart wall.The coring abutment 145 can resist motion of the heart wall away fromthe coring blade 137, compressing the heart wall between the coringblade 137 and the coring abutment 145. The coring blade 137 can beextended until the coring blade 137 contacts the coring abutment 145,coring the heart wall. The heart wall can be cored coaxial (i.e., alongsubstantially the same longitudinal axis) with the valvular structure 12and/or attachment ring 22.

In an alternative variation of the coring knife 140 with the coringabutment 145 having a smaller outer diameter than the inner diameter ofthe cutting edge of the coring blade 137, the coring blade 137 can beextended until the coring blade 137 passes adjacent to the coringabutment 145, shearing the cored tissue 175 between the coring blade 137and the outer circumference of the coring abutment 145.

The coring knife 140 can be withdrawn and removed from the heart 106,attachment ring 22 and valvular structure 12 with the coring blade 137pressed against the coring abutment 145 to form a closed volume in thecoring blade 137. The core of heart tissue formed by the coring blade137 can be stored within the coring blade 137 and removed from thetarget site with the coring knife 140.

FIG. 40f illustrates that the inflow conduit 10 of the pump 8 (pump 8not shown in FIG. 400 can be translated, as shown by arrow 183, into thevalvular structure 12 and the attachment ring 22. The inflow conduitstop 42 can abut and interference fit against the housing 18, stoppingtranslation of the inflow conduit 10.

The valvular structure 12 and attachment ring 22 can be de-aired byapplying suction to the de-airing port 62 of the valvular structure 12and/or injecting saline or blood into the de-airing port 62. Thevalvular structure 12 can be de-aired once during the implantation ofthe ventricular assist system or multiple times throughout theimplantation, for example immediately before and/or after insertion ofthe inflow conduit 10 through the valvular structure 12.

After the inflow port 7 of the inflow conduit 10 is located in the heart106 and/or past a fluid tight seal formed against the attachment ring 22(e.g., with the attachment ring seal 34) and/or the valvular structure12 (e.g., with the housing seal 47 and/or valve 16), the valvularstructure 12 can be removed from the attachment ring 22. For example,the first joint latch 69 can be opened, as shown by arrows 168. Thehousing first portion 46 and housing second portion 54 can then berotated open and removed from the attachment ring 22, as shown by arrows169.

FIG. 40g illustrates the valvular structure 12 in a configuration whenbeing opened and in the process of being removed from the inflow conduit10. A first portion of the valvular structure 12 can be rotated awayfrom a second portion of the valvular structure 12. For example, theinter-leaflet seam 64 can open at a lateral perimeter surface of thevalve 16, splitting open the valve 16 along the respective housing seam51 or 49, and the housing first portion 46 can rotate open away from thehousing second portion 54 at a hinge at the housing second seam 48. Whenthe housing 18 is removed, the valve 16 can separate from the housing 18and remain on the inflow conduit 10. The valve 16 can then be rotatedopen at the end of an interleaf seam that extends to but not through thevalve shoulder 59 (with the valve shoulder 59 acting as a hinge), asshown in FIG. 40g , and/or cut or torn at the interleaf seam and pulledaway from the inflow conduit 10. The valve 16 can be removed with thehousing 18 from the inflow conduit 10, as shown in FIG. 40g , or afterthe housing 18 is removed from the inflow conduit 10. FIG. 40hillustrates the inflow conduit 10 and attachment ring 22 following theremoval of the valvular structure 12. The pump 8 is not shown but isattached to the distal end of the inflow conduit 10. The inflow conduit10 can have an indicator that the pump 8 should be attached to thedistal end of the inflow conduit 10.

FIG. 40i illustrates that the inflow conduit 10 can be furthertranslated, as shown by arrows, into the left ventricle 165. The inflowconduit 10 can be translated until the inflow conduit stop 42interference fits against the ring wall interference lip. The clamphandle 36 can then be closed, as shown by arrow 170, reducing thediameter of the clamp 24 and pressure fitting or compressing the insideof the attachment ring 22 against the outside of the inflow conduit 10,reducing or preventing translation of the inflow conduit 10 with respectto the attachment ring 22. The outside surface of the inflow conduit 10can form a fluid-tight seal against the inside surface of the attachmentring 22 for example at the attachment ring seal 34. The inflow conduit10 can be removed or repositioned, for example, by opening the clamphandle 36, removing or repositioning the inflow conduit 10, and thenclosing the clamp handle 36.

The heart 106 can pump blood during the creation of the slit, insertionof the coring abutment 145 into the ventricle, coring, insertion of theinflow conduit 10 into the heart 106, removal of the valvular structure12, tightening of the clamp 24 around the attachment ring 22, orcombinations or all of the above.

FIGS. 41a through 41d illustrate a method of coring a portion of theheart wall using a variation of the coring knife 140 similar to thevariation shown in FIG. 38. FIG. 41a illustrates that the coring knife140 can be placed adjacent to a valvular structure 12 with a diaphragmvalve 16. FIG. 41b illustrates that the coring knife 140 can be insertedthrough the diaphragm port 83. The diaphragm port can elastically deformto accommodate the coring knife 140 passing through the diaphragm port.The diaphragm can form a fluid-tight seal around the coring knife 140 asthe coring knife 140 is inserted into the diaphragm port. The foreblade152 can be extended out of the distal end of the knife head 136 andpressed into the heart wall, as shown by arrow. The foreblade 152 cancut or slit the heart 106. The knife head 136 can be pushed into theslit or cut in the heart wall made by the foreblade 152.

FIG. 41c illustrates that the knife handle 139 can be translated towardthe heart 106, extending the knife head 136 into the left ventricle 165,as shown by arrow. The coring abutment 145 can be facing the innersurface of the heart wall. The foreblade 152 can be retracted to beatraumatically covered by the knife head 136.

FIG. 41d illustrates that the knife handle 139 can be translated awayfrom the heart 106, retracting the knife head 136 toward the coringabutment 145, as shown by arrow. The coring abutment 145 and coringblade 137 can cut tissue away from the heart wall. The coring abutment145 and coring blade 137 can shear (if the coring abutment 145 has asmaller diameter than the diameter of the coring blade 137) or chop (ifthe coring abutment 145 has a diameter larger than or equal to thediameter of the coring blade 137) the tissue. Cored tissue 175 can bestored within the internal volume of the coring blade 137 until afterthe coring knife 140 is removed from the valvular structure 12. When thecoring knife 140 is removed from the valvular structure 12, thediaphragm can close, preventing or minimizing blood flow from the heart106 from exiting the valvular structure 12.

FIGS. 42a through 42c illustrate a method of using a valvular structure12 having a locking ring 98 to clamp the attachment ring 22 to theinflow conduit 10. FIG. 42a illustrates that the inflow conduit 10 canbe inserted, as shown by arrow, through the valvular structure 12 havinga diaphragm valve 16 (the diaphragm can be elastically deformed out ofthe way of the inflow conduit 10 but is not shown for illustrativepurposes). The diaphragm port 83 can elastically expand to accommodatethe inflow conduit 10. The diaphragm port 83 can form a fluid-tight sealaround the inflow conduit 10, preventing blood from flowing from theheart 106 out the valvular structure 12.

FIG. 42b illustrates that the tape 89 can then be removed from thevalvular structure 12. The housing 18 can then be separated into thehousing first portion 46 and the housing second portion 54 componentsand removed from the target site. The diaphragm valve 16 can then beremoved, such as by being torn or cut away from the inflow conduit 10 orremoved with the housing 18 when the diaphragm seam 88 opens.

FIG. 42c illustrates that the locking ring 98 can be forced toward theheart 106, as shown by arrow. In the configuration shown in FIG. 42c ,the locking ring 98 can compress the ring wall 29. The inner diameter ofthe ring wall 29 can be reduced by the compressive pressure from thelocking ring 98. The radially inner surface of the attachment ring wall29 can compress against and press-fit to the radially outer wall of theinflow conduit 10, forming a fluid-tight seal. The locking ring 98 canbe pulled away from the heart 106, relaxing and expanding the attachmentring wall 29, for example reducing the force of or completelyeliminating the press fit between the radially inner surface of theattachment ring wall 29 and the radially outer surface of the inflowconduit 10.

FIGS. 43a and 43b illustrate a variation of a method for de-airing theoutflow conduit 2. FIG. 43a illustrates that when the blood flow in theoutflow conduit 2 is stanched by a clamp 131 (as shown) or balloon 135,a balloon catheter 132 can be inserted through the wall of the outflowconduit 2. The pump 8 can be de-aired, for example the pump 8 can be runwhen in fluid communication with the ventricle, or the pump 8 can bepre-loaded with saline or blood. The balloon 135 can then be insertedinto the terminal outflow end of the pump 8 and inflated, for examplemaintaining the pump 8 and inflow conduit 10 in a de-aired condition(i.e., with no air within the fluid channel of the pump 8 or the inflowconduit 10).

FIG. 43b illustrates that the outflow conduit 2 can be joined to thepump 8 at the outflow conduit coupler 4. The clamp 131 can be removedfrom the outflow conduit 2 before coupling the outflow conduit 2 to thepump 8, allowing blood from the aorta 104 to de-air the outflow conduit2 and then the outflow conduit 2 can be joined to the pump 8.

Alternatively, the outflow conduit clamp 131 can remain on the outflowconduit 2 after the outflow conduit 2 is joined to the pump 8. Theballoon 135 can then be removed from the pump 8 and outflow conduit 2,and the pump 8 can be run. The air from the outflow conduit 2 betweenthe outflow conduit clamp 131 and the pump 8 can be forced out throughthe hole in the side wall of the outflow conduit 2 directly or drawn outvia a needle inserted into the outflow conduit 2. If a balloon catheterwith side ports is used, the catheter ports can be used to withdraw airinstead of using the hole in the graft or an additional needle.

Once the outflow conduit 2 and the remainder of the system is de-aired,the balloon 135 (as shown) and/or outflow conduit clamp 131 can beremoved from the outflow conduit 2. If a catheter 132 was removed fromthe wall of the outflow conduit 2, a suture can be sewn if needed, suchas by a purse stitch, into the outflow conduit 2 to close the hole inthe outflow conduit wall.

Alternatively, when the outflow conduit 2 is occluded by the balloon 135or clamp 131, the pump 8 can be attached to the outflow conduit 2 andoperated. Excess air in the ventricular assist system can be withdrawnwith a catheter 132 or the bi-material balloon described herein.

FIG. 44 illustrates another variation of a method for de-airing thesystem using a liquid-filled de-airing bladder, enclosure or pouch toprevent air from entering the VAD components during assembly of theoutflow conduit 2 and the pump 8. The outflow conduit coupler 4, outflowend of the pump 8 and the end of the outflow conduit 2 to be attached tothe pump 8 can be placed in the de-airing pouch 179. The de-airing pouch179 can be filled with saline before or after placing the VAD componentsin the de-airing pouch 179. The attachment ring 22 can be previouslyde-aired through the de-airing port 62 on the valvular structure 12. Theoutflow conduit 2 can be previously de-aired with blood flow from theaorta 104 and stanching, for example, with an outflow conduit clamp 131or balloon 135. The pump 8 and inflow conduit 10 can be pre-filled withsaline or blood before delivery into the target site. The outflow portof the pump 8 can be plugged before the pump 8 is delivered into thetarget site.

When the outflow end of the pump 8 and the inflow end of the conduit arelocated in the de-airing pouch 179, the balloon 135 in the outflowconduit 2 can be deflated and removed or the outflow conduit clamp 131on the outflow conduit 2 can be removed. The blood flowing from theaorta 104 can de-air the outflow conduit 2, purging air in the outflowconduit 2 into the de-airing pouch 179. The purged air can then escapefrom the de-airing pouch 179 or travel to a portion of the de-airingpouch 179 away from the openings of the VAD components. The pump 8 canbe driven to pump blood through the inflow conduit 10 and pump 8 todrain any additional air from the pump 8 and inflow conduit 10. Theoutflow conduit 2 can then be attached to the pump 8 in the de-airingpouch 179 or without a de-airing pouch 179, as shown in FIG. 43b or 45.

The percutaneous lead 5 can be attached to the pump 8 and to externalpower, control and data transmission devices as known in the art.

The system can be implanted when the heart 106 is beating and thepatient is not on cardio-pulmonary bypass. However, the system can beimplanted with the patent on cardio-pulmonary bypass and the heart 106slowed or stopped. The system can be implanted using less invasivetechniques described herein, but can be implanted with a fullthoracotomy and sternotomy.

In FIGS. 46a and 46b , another embodiment of attachment ring 22 isformed by injection molding a polymer in a mold containing reinforcementelements which are to be imbedded or encased within the polymer. Themold cavity includes geometric features that simultaneously forminterface lip 25, cylindrical ring wall 29 which forms a tubular fluidpassageway, distal band 31, and ring seal 34 as a single, unitarystructure. Ring seal 34 forms the circular, inner edge of the proximalopening to ring channel 14.

Attachment ring 22 is flexible. The polymer used for molding can besilicone rubber, although other polymers suitable for implantation maybe used. When completely cooled and/or cured after molding, the polymeris flexible and elastic to allow ring seal 34 to flex, conform, and sealagainst a cylindrical object that is inserted through ring channel 14.The reinforcement elements include proximal reinforcement band 202,distal reinforcement band 204, and fiber mesh 206. Proximal and distalreinforcement bands 202, 204 can be made of a material that is morerigid than the polymer injected into the mold and which forms theremainder of attachment ring 22. The additional rigidity providedproximal and distal reinforcement bands 202, 204 help openings at theopposite ends of ring channel 14 maintain a circular shape. Proximal anddistal reinforcement bands 202, 204 can be made of Nylon, acetal,polycarbonate, HDPE, PP, PET, PEEK, titanium or stainless steel. Fibermesh 206 can be made of polyester fibers that have been braided to forma mesh tube which is then placed in the mold as part of the moldingprocess. Other types of fibers and mesh configurations can be used.Fiber mesh 206 can be distributed within distal band 31 and ring wall29. Fiber mesh 206 helps prevent the polymer from tearing due tomechanical stress, such as may be arise from sutures used later toattach cuff 35 to distal band 31. Flared ends of fiber mesh 206 providepositive fixation of sutures to the polymer substrate of distal band 31.

Attachment ring 22 can be rotationally symmetric about longitudinal axis200, so that interface lip 25, ring wall 29, distal band 31, ring seal34, proximal reinforcement band 200, and distal reinforcement band 202are each annular in shape.

After molding, cuff 35 can be attached to distal band 31 by passing aneedle with suture 208 through cuff 35 and distal band 31. Suture 208can be a continuous, non-bioerodable fiber or thread that is looped in ahelical manner through the outer perimeter of distal band 31. Oppositeends of suture 208 can be tied in a knot 208 a to prevent loosening.Portion 29 a of ring wall 29 extends distally beyond distal band 31.Portion 29 a helps to center the hole in cuff 35 with ring channel 14 sothat no portion of cuff 35 obstructs ring channel 14. In subsequentclinical use of attachment ring 22, cuff 35 is attached to a patient'sheart and ring clamp 24 can be used to secure inflow conduit 10 withinring channel 14.

The molding process allows ring seal 34 to be formed, in a consistentmanner, with a diameter and round shape that corresponds to the size ofinflow conduit 10, so that a fluid-tight seal between attachment ring 22and exterior surfaces of inflow conduit 10 results when inflow conduit10 is disposed within attachment ring 22

In FIGS. 47a-47c , another embodiment of attachment ring 22 is formed bymolding a polymer into a sheet in which fiber mesh 206 is embedded orencased. Suitable materials for the polymer and fiber mesh can be asdescribed for FIGS. 46a-46d . As shown in FIGS. 47a and 47b , attachmentring 22 can be made by cutting out a rectangular strip 210 from the flatsheet, rolling strip 210 so that opposite ends 212 of the strip overlap,and bonding ends 212 together to form a fluid-tight seam 214.

Next, cuff 35 can be attached around distal portion 216 of the rolledstrip by passing a needle with suture 208 through cuff 35 and distalportion 216. A single, continuous piece or several pieces of suture 208can be used to secure proximal edge 218 and distal edge 220 of cuff 35to distal portion 216 of the rolled strip. In subsequent clinical use ofattachment ring 22, cuff 35 is attached to a patient's heart and ringclamp 24 can be used to secure inflow conduit 10 within ring channel 14.Interior edge 214 a of seam 214 extends through the entire length ofring channel 14. End 212 a of the strip which forms interior edge 214 acan be tapered in cross-section so as to form a smooth interface withopposite end 212 b. Material can also be added at interior edge 214 a toform the smooth interface. The smooth interface allows the inner surfaceof ring channel 14 to form a fluid-tight seal against inflow conduit 10.

In FIGS. 48a and 48d , another embodiment of attachment ring 22 isformed by injection molding a polymer in a mold cavity having geometricfeatures that simultaneously form ring wall 29, distal band 31, ringseal 34, and ring valve 230 as a single, unitary structure. Suitablematerials for the polymer can be as described for FIGS. 46a-46d . FIGS.48a and 48c show views of the distal end and proximal end, respectively.FIGS. 48a and 48b show attachment ring 22 without cuff to better showfeatures of distal band 31.

Attachment ring 22 can be rotationally symmetric about longitudinal axis200, so ring wall 29, distal band 31, and ring seal 34 are each annularin shape. In the illustrated embodiment, ring valve 230 is a quadcuspid(i.e., four-leaflet) valve similar in configuration to valve 16described in connection with FIGS. 12a and 15c . Other configurationsfor valve 230 can be implemented, for example and without limitation atricuspid valve (similar to FIG. 14a ), a bicuspid valve (similar toFIG. 15a ), a dome valve, a diaphragm valve (similar to FIG. 15f ), andcombinations thereof. Ring seal 34 forms the circular, inner edge of theproximal opening of ring channel 14. When a cylindrical object (forexample, slitting tool 300 and coring knife 140) is inserted into theproximal opening of ring channel 14, ring seal 34 seals against thecylindrical object and ring valve 230 flexes open. When the cylindricalobject is removed, ring valve 230 closes autonomously to reduce, preventor inhibit fluid from flowing distally through ring valve 230 in thedirection of arrow 231. With attachment ring 22 attached to the heart,ring valve 230 can allow slitting and coring of heart tissue while theheart is beating and pumping without the use of valvular structure 12.

After molding, cuff 35 can be attached to distal band 31 by passing aneedle with suture 208 through cuff 35 and distal band 31, such asdescribed for FIGS. 46c and 46d . In subsequent clinical use ofattachment ring 22, cuff 35 is attached to a patient's heart and ringclamp 24 can be used to secure inflow conduit 10 within ring channel 14.

Attachment ring 22, in any of the embodiments described above, mayinclude an alignment feature that allows a slitting tool and coringknife 140 to share common alignment. A slitting tool is shown in FIGS.52a-52c . In use, the slitting tool can be inserted into attachment ring22. When inserting the slitting tool into attachment ring 22, thealignment feature ensures that the flat blade of the slitting tool isoriented in a particular way, as will be described in more detail below.Once aligned, the flat blade extends to form a slit in the heart tissue,then the slitting tool is removed from attachment ring 22. The slitfunctions as a passage through which elements of coring knife 140 can beinserted. When inserting coring knife 140 into attachment ring 22, thealignment feature ensures that rotatable coring abutment 145, such asshown in FIGS. 37a-37d , is oriented along the same line as the slitpreviously formed by the slitting tool and thereby allows of easy entryof coring abutment 145 into the heart cavity.

Alignment feature can take the form of a structural feature, such as twoindentations 230 (FIG. 4a ) formed into interface lip 25 at the proximalend of attachment ring 22. Indentations 230 can be shaped and sized toreceive protrusions 346 on the exterior surface of the slitting tool(see FIG. 52a ) and protrusions 411 on the exterior surface of thecoring knife (see FIG. 54). Indentations 230 allow for “blind” alignmentwhereby engagement of indentations and protrusions provide tactilefeedback to the surgeon or other user which indicates proper alignment.Alignment feature can also take the form of a visual indicator, such asindelible markings 232 (FIG. 46c ) in a contrasting color and/or anembossed marking applied on interface lip 25. In use, a pair ofprotrusions or markings on the exterior surface of the slitting tool canbe aligned with markings 232 during insertion of the slitting tool intoattachment ring 22. Subsequently, a pair of protrusions or markings onthe exterior surface of coring knife 140 can be aligned with markings232 during insertion of coring knife 140 into attachment ring 22.

Referring again back to FIG. 7a , clamp 24 can be disposed around thecentral portion of attachment ring wall 29 located between interface lip25 and cuff 35. Clamp 24 can be installed and removed from attachmentring 25 by translating it axially, in a direction along longitudinalaxis 200, onto attachment ring 22 until it reaches the central portionof attachment ring wall 29. However, in cases where clamp 24 has limitedability enlarge its clamp diameter 38, interface lip 25 and cuff 35could interfere with axial translation of attachment ring 22, makinginstallation and removal of attachment ring 22 difficult especiallyafter attachment ring 22 has been secured to heart tissue.

In FIGS. 49a-49d , another embodiment of clamp 24 is shown havingmultiple linkages that allow clamp 24 to be easily installed and removedfrom attachment ring 22, either before or after attachment ring 22 hasbeen secured to heart tissue. The linkages are in the form of firstcurved piece 240, second curved piece 242, lever 244, and third curvedpiece 246. When clamp 24 is closed (FIG. 49a ), inner surfaces of first,second and third curved pieces 240, 242, 246 form a circle havingdiameter 247 needed to allow the curved pieces to apply pressure toattachment ring wall 29 in order to secure inflow conduit 10 toattachment ring 22. Diameter 247 can be about the same as or slightlysmaller (for example, 5%, 10%, or 20% smaller) than the outer diameterof attachment ring wall 29. The linkages can be pivoted relative to eachother so as to create an opening that is larger that the outer diameterof attachment ring wall 29. With this ability, attachment ring 22 can beinstalled and removed from attachment ring 22 in a manner that avoidsinterference from interface lip 25 and cuff 35.

Referring to FIG. 49b , the ends of first curved piece 240 and secondcurved piece 242 are pivotally connected to each other by primary hinge241. The opposite end of first curved piece 240 has hook 245. Theopposite end of second curved piece 242 is connected to lever 244 byfirst lever hinge 248. Second lever hinge 250 connects medial part 252of lever 244 to one end of third curved piece 246. Medial part 252 isdisposed between two legs 254 of third curved piece 246. The oppositeend of curved piece 246 has cylindrical catch 256. Cylindrical catch 256connects legs 254 together and is sized and shaped to fit within hook245.

FIG. 49a shows clamp 24 when closed. Lever 244 is disposed within groove243 (FIG. 49b ) formed within second curved piece 242 and between legs254 of third curved piece 246. Cylindrical catch 256 is seated withinhook 245. First lever hinge 248 is positioned adjacent hook 245.

When clamp 24 is closed, movement of third curve piece 246 along thedirection of arrow 260 is prevented by the presence of attachment ringwall 29 and inflow conduit 10 within clamp 24. That is, attachment ringwall 29 and inflow conduit 10 prevent inner diameter 247 of clamp 24from getting smaller.

To open clamp 24, a person can pull protrusion 258 at the free end oflever 244 radially outward in the direction of arrow 262, as shown inFIG. 49b . Movement of protrusion 258 along arrow 260 causes cylindricalcatch 256 to move along arrow 260, without requiring inner diameter 247to get smaller. Thus, the presence of attachment ring wall 29 and inflowconduit 10 within clamp 24 does not prevent cylindrical catch 256 fromdisengaging hook 245 when protrusion 258 is pulled along arrow 260. Oncedisengaged first curve piece 240 can be pivoted about primary hinge 241to create an opening that is substantially larger than diameter 247, asshown in FIG. 49 c.

Clamp 24 can have a provision for locking lever 244 in the closedposition. Through hole 264 is formed through the free end of lever 244.When in the closed position, as shown in FIG. 49a , first opening 266 ofthe through hole is exposed and second opening 268 (FIG. 49b ) isdisposed within groove 243 in second curved piece 242. Second opening268 faces the opening of through hole 267 in second curved piece 242which extends to the outer surface of second curved piece 242. Throughhole 264 and through hole 267 can be aligned so as to be coaxial, whichallows a suture to be looped through both through holes. The sutureprevents lever 244 from moving out in direction of arrow 262 and therebykeeps clamp 24 closed. Opposite ends of the suture can be tied togetherin a knot to keep the suture in place. The suture can be cut to allowits removal and to allow clamp 24 to be opened.

In FIGS. 50a and 50b , another embodiment of clamp 24 is shown having asingle, unitary structure in the form of ring 270 with detachable ends.The ends have ratchet features that interlock with each other and allowinner diameter 272 of ring 270 to become smaller. First end 274 includesguard member 276 and ratchet member 278 with a plurality of radiallyinward facing teeth 280. Second end 282 includes ratchet member 284 witha plurality of radially outward facing teeth 286. Ratchet member 284 isdisposed within an open channel between guard member 276 and ratchetmember 278. When clamp 24 is open, as shown in FIGS. 50a and 50b , gap280 exists between the free end of ratchet member 284 and the end of theopen channel between guard member 276 and ratchet member 278. Gap 280allows first end 274 and second end 282 to pushed together, which causesteeth 280 and teeth 286 to engage each other. Teeth 280 and teeth 286are configured to slip past each other when first end 274 and second end282 are pushed together and are configured to engage each other toprevent first end 274 and second end 282 from subsequently moving apartfrom each other. In use, clamp 24 can be disposed around attachment ringwall 29 of attachment ring 22. Guard member 276 prevents attachment ringwall 29 from being pinched within gap 280.

Ring 270 functions like a spring in that it stores spring energy whenfirst end 274 and second end 282 are pushed together. Ring 270 can beformed by injecting a polymer into a mold cavity that includes geometricfeatures that simultaneously form guard member 276, ratchet member 278,teeth 280, ratchet member 284, and teeth 286 as a single, unitarystructure. Through hole 288 is formed in first end 274. Through hole 290is formed in second end 282. Through hole 288 and through hole 290 canreceive tips of a tool for pushing first end 274 and second end 282together. Through hole 300 is formed in ratchet member 278. Opposingteeth 280, 286 can be disengaged from each other by inserting a tool inthrough hole 300 and pulling radially outward. When opposing teeth 280,286 disengage, first end 274 and second end 282 autonomously move apartfrom each other due to the spring energy stored in ring 270.

After pushing first end 274 and second end 282 together, a suture can belooped into through hole 300 and through hole 290 as a security measureto prevent the ratchet members from inadvertently disengaging. Oppositeends of the suture can be tied together in a knot to keep the suture inplace. The suture can be cut to allow its removal and to allow ratchetmembers to disengage and inner diameter 272 to enlarge.

When clamp 24 is open, as shown in FIGS. 50a and 50b , inner diameter272 is larger than the outer diameter of attachment ring wall 29 ofattachment ring 22. When clamp 24 is closed by pushing the first end 274and second end 282 together, inner diameter 272 corresponds to the sizeof inflow conduit 10 plus the thickness of attachment ring wall 29, sothat a fluid-tight seal between attachment ring 22 and exterior surfacesof inflow conduit 10 results when inflow conduit 10 is disposed withinattachment ring 22.

In FIG. 51, another embodiment of clamp 24 is shown having ratchetmembers 278, 284, each with only one tooth 286, 280. Other embodimentsmay have any number of teeth, as may be needed, to provide additionalengagement and/or to allow clamp 24 to be used with attachment rings 22and inflow conduits 10 of different sizes.

After attachment ring 22 is attached to heart apex 119, foreblade 152 ofcoring knife 140 of FIG. 38 can be used to form a slit through theepicardium and into the myocardium at heart apex 119. Alternatively,slitting tool 300 of FIGS. 52a-52c can be used to form the slit into theheart.

As shown in FIG. 52a , cylindrical housing 302 has front end 304 andrear end 306. Rear end 306 includes radially protruding handles 308.Spring-loaded actuator 310 protrudes axially out of rear end 306 and isconnected to a flat blade contained within housing 302. Pushing actuator310 axially forward in the direction of arrow 312 causes the flat bladeto extend out of slit opening 314 at front end 304.

As shown in FIG. 52b , spring 316 is contained within a rear segment ofhousing 302. Rear end 318 of spring 316 is attached to a medial segmentof actuator 310. Forward end 320 of spring 316 abuts wall 322 withinhousing 302. Spring 316 and flat blade 326 are contained within housing302 at opposite sides of wall 322. Spring 316 is under compression andkeeps the flat blade completely retracted within housing 302 until auser pushes actuator 310. Actuator 310 extends through a hole in wall322. Forward end 324 of actuator 310 is connected to flat blade 326. Asactuator 310 is translated forward in the direction of arrow 312,actuator 310 compresses spring 316 against wall 322 and forward end 324pushes blade 326 out of front end 304 of housing 302.

FIG. 52c shows flat blade 326 extending out of slit opening 314 afteractuator 310 has been pushed forward. Blade seal 328 is contained withinhousing 302 and is located adjacent slit opening 314 at front end 304.Flat blade 326 passes through blade seal 328 which includes a pair offlexible wipers 330 that face each other. Wipers 330 extend across theentire blade width 332 (FIG. 52b ) and press against opposite sides offlat blade 326, thereby preventing blood from flowing into the rearsegment of housing 302. Blade seal 328 can be made of silicone rubber orother resilient polymer. In other embodiments, blade seal 328 is a stripof polymer foam with a slit equivalent in size to blade width 332.

In use, front end 304 of housing 302 is inserted into attachment ring 22or the combination of valvular structure 12 and attachment ring 22.Outer diameter 330 of housing 302 and ring seal 34 of attachment ring 22can be sized such that a substantially fluid-tight seal is formedbetween the exterior surface of housing 302 and ring seal 304 when frontend 304 is inserted into through attachment ring 22. When flat blade 326punctures a beating heart and is retracted, blood from the heart mayflow into attachment ring 22 and into slit opening 314 of housing 302.Blade seal 328 minimizes blood loss by preventing or inhibiting bloodfrom flowing through and out of slitting tool 300.

In some embodiments, outer diameter 330 of housing 302 and housing seal47 (FIG. 10a ) of valvular structure 12 can be sized such that asubstantially fluid-tight seal is formed between the exterior surface ofhousing 302 and housing seal 47 when front end 304 is inserted intovalvular structure 12 which has been attached to attachment ring 22.When flat blade 326 punctures a beating heart and is retracted, bloodfrom the heart may flow into attachment ring 22, valvular structure 12,and slit opening 314 of housing 302. Blade seal 328 minimizes blood lossby preventing or inhibiting blood from flowing through and out ofslitting tool 300.

Referring again to FIG. 52a , stop feature 340 is located on housing 320at a predetermined distance 342 from the forward most tip 344 ofslitting tool 300. Stop feature 340 prevents tip 344 from pushing intothe heart when slitting tool 340 is being positioned within attachmentring. Stop feature 340 includes a pair of protrusions 346 sized andshaped to fit within alignment features on attachment ring 22 and/orvalvular structure 12.

In some embodiments, predetermined distance 342 is equivalent to or afew millimeters less than the longitudinal height of attachment ring 22.The longitudinal height can be the maximum dimension as measured alongthe longitudinal axis of attachment ring 22. The longitudinal height ofan exemplary attachment ring is indicated by arrow 348 in FIG. 46d . Inuse, slitting tool 300 can be inserted by a surgeon or other user intoattachment ring 22 secured to the heart, with no valvular structure 12attached to attachment ring 22. When stop feature 304 abuts interfacelip 25 of attachment ring 22, the user will know that tip 344 ofslitting tool 300 is located at the proper position just above theheart. The user can twist slitting tool 300 about its central axis 301until protrusions 346 become seated within indentations 230 (FIG. 4a )formed into interface lip 25. When protrusions 346 engage indentations230, the user will know from tactile feed back that slitting tool 300 isin proper rotational alignment. Thereafter, the user can extend flatblade 326 to make a slit through the heart, and then use coring knife140 under the same rotational alignment as slitting tool 300 to form acircular hole around the slit.

In some embodiments, predetermined distance 342 is equivalent to or afew millimeters less than the longitudinal stack height of valvularstructure 12 and attachment ring 22. The longitudinal stack height of anexemplary assembly of valvular structure 12 and attachment ring 22 isindicated by arrow 350 in FIG. 2b . In use, slitting tool 300 can beinserted by a surgeon or other user into valvular structure 12 andattachment ring 22 which has been attached to the heart. When stopfeature 304 abuts the proximal end of valvular structure 12, the userwill know that tip 344 of slitting tool 300 is located at the properposition just above the heart. The user can twist slitting tool 300about its central axis 301 until protrusions 346 become seated withinalignment features (for example, coupling grooves 71 (FIG. 11a ),alignment groove 497 (FIG. 56a ) and alignment groove (FIG. 57a ))formed into the proximal end of valvular structure 12. When protrusions346 engage the alignment features, the user will know from tactile feedback that slitting tool 300 is in proper rotational alignment.Thereafter, the user can extend flat blade 326 to make a slit throughthe heart, and then use coring knife 140 under the same rotationalalignment as slitting tool 300 to form a circular hole around the slit.

Stop feature 340 can be an annular flange, as illustrated, which can bean integral part of or permanently affixed to housing 320. Protrusions346 can be spaced 180 degrees apart from each other on the circumferenceof stop feature 340. Alternatively, stop feature 304 can be movablealong housing 302 to allow predetermined distance 342 to be adjusted ifdesired.

In FIGS. 53a-53f , another embodiment of coring knife 140 is shownhaving pistol-type grip 360, release trigger 362, and abutment controllever 364. FIG. 53a shows coring knife 140 in its startingconfiguration, in which the plane of coring abutment 145 is in line withlongitudinal axis 366 of coring knife 140, and coring blade 137 iscompletely contained within coring knife case 141. The plane of thecoring abutment 145 is defined by a plurality of points on the outerperimeter of coring abutment 145. Coring abutment 145 is held inposition by two support rods 368. Control arm 146 is disposed betweensupport rods 368. Support rods 368 and control arm 146 extend into theforward end of slide assembly 370 and into central shaft 372 (FIG. 53d )which is fixedly attached to grip 360. The forward ends of support rods368 and control arm 146 are pivotally connected to different points oncoring abutment 145. Control arm 146 is operatively coupled to abutmentcontrol lever 364.

As shown in FIG. 53b , the forward ends of support rods 368 are attachedto coring abutment 145 at points 372 that form pivot line 374 that issubstantially perpendicular to longitudinal axis 366. The forward endsof support rods 368 can be attached to coring abutment 145 by a slenderpin that extends within coring abutment 145. Control arm 146 is attachedto coring abutment 145 at point 376 which is longitudinally offset byoffset distance 377 from points 372 so as to be closer to forward mosttip 378 of coring abutment 145. The forward end of control arm 146 canbe attached to coring abutment 145 by another slender pin that extendswithin coring abutment 145. Due to offset distance 377, movement ofcontrol arm 146 rearward in the direction of arrow 380, while supportrods 368 remain stationary, causes coring abutment 145 to rotate aboutpivot line 374. As shown in FIG. 53c , when point 376 has moved rearwardby a distance equivalent to offset distance 377, the plane of coringabutment 145 is substantially perpendicular to longitudinal axis 366.Control arm 146 is operatively coupled to control lever 366 which ispivotally attached to grip 360. As shown in FIG. 53d , pivoting controllever 366 upward in a direction along arrow 382 causes control arm 146to move rearward along arrow 380 until the plane of abutment surface 145is substantially perpendicular to longitudinal axis 366. Control lever364 includes safety latch 384. When control lever 366 is in a loweredposition (FIG. 53a ), safety latch 384 is in front of knob 385 of slideassembly 370 where it prevents slide assembly 370 from inadvertentlysliding toward coring abutment 145. When control lever 366 is in araised position (FIG. 53d ), safety latch 384 has moved away from knob385 and slide assembly 370 can slide toward coring abutment 145 whenrelease trigger 362 is pressed by the user.

Slide assembly 370 comprises coring blade 137, coring knife case 141,and internal sleeve 386. Internal sleeve 386 (FIG. 53f ) is disposedaround and slides longitudinally over central shaft 372. Coring knifecase 141 is fixedly attached to internal sleeve 386. Internal sleeve 386includes a pair of linear slots 388 (FIG. 53f ) which extendsubstantially parallel to longitudinal axis 366. Pin 390 (FIG. 53e )protrudes from central shaft 372 into linear slots 388 and therebyprevents internal sleeve 386 from rotating relative to central shaft 372and grip 360. Pin 390 prevents internal sleeve 386 from rotatingrelative to central shaft 372. Internal sleeve 386 also includes aseries of holes 392 arranged along one or more lines substantiallyparallel to longitudinal axis 366. A ball detent mechanism withincentral shaft 372 engages one or more of the holes 392 to prevent slideassembly 370 from sliding freely on central shaft 372. Ball detentmechanism is operatively coupled to release trigger 362. Release trigger362 is spring loaded in such a way that ball detent mechanism preventsslide assembly 370 from sliding when no force is applied to releasetrigger 362.

When a force is applied by a user to depress release trigger 362, balldetent mechanism disengages holes 392. The user may then grasp slideassembly 370 and slide it forward toward coring abutment 145, as shownin FIG. 53e . In use, slide assembly 370 is preferably moved forward toa point where forward edge 396 of coring knife case 141 touches or isjust above the heart tissue 398. It is understood that coring knife case141 is now located within the ring channel 14 of attachment ring 22 orvalvular structure 12 combined with attachment ring 22. It is alsounderstood that the coring abutment 145 is located within the heartcavity and abuts the heart tissue from the side opposite coring knifecase 141. When forward edge 396 of coring knife case 141 is at thedesired position, the user may let go of release trigger 362 so thatball detent mechanism engages holes 392 and locks in the longitudinalposition of coring knife case 141.

At this stage, coring blade 137 remains completely retracted withincoring knife case 141. Coring blade 137 is a hollow cylinder the forwardend of which forms sharp circular tip 400. The rear end of coring blade137 is fixedly attached to the front end of rotatable control sleeve402. Helical coring guide or slot 147 is formed into the rear segment ofrotatable control sleeve 402. Knob 385 is fixedly attached to the rearend of control sleeve 402. Manual rotation of knob 385 by the usercauses control sleeve 402 and coring blade 137 to rotate relative tocoring knife case 141 and internal sleeve 386 which are held stationaryby ball detent mechanism and pin 390. Guide peg 148 protrudes fromcoring knife case 141 into helical slot 147 of control sleeve 402. Thus,rotation of knob 385 simultaneously causes control sleeve 402 and coringblade 137 to translate longitudinally toward coring abutment 145.Rotation in the reverse direction causes control sleeve 402 and coringblade 137 to translate longitudinally away from coring abutment 145. Itis understood that knob 385 allows the user to have complete control ofthe force applied by coring blade and complete control of coring bladeadvancement by each turn of knob 385. In this embodiment, there is nospring loading on coring blade 137 that might otherwise remove completecontrol of applied force from the user.

In FIG. 53f , knob 385 has been rotated until circular tip 400 of coringblade 137 has pressed against coring abutment 145. In use, coring blade137 would have made a circular cut entirely through the myocardium. Around piece of polymer foam, absorbent material, or resilient material,can be disposed within the rear end of the coring blade 137 to sealaccess holes for support rods 368 and control arm 146, and thereby stopor soak up blood and prevent blood from rushing into the rear portionsof coring knife 140. A cylindrical portion of the myocardium would becompletely detached from the remainder of the heart and contained withincoring blade 137. The user may then pull coring knife 140 rearward, in adirection substantially parallel to longitudinal axis 366, therebyextracting the cylindrical portion of the myocardium out from beneathattachment ring 22 or the combination of valvular structure 12 andattachment ring 22. If the procedure is performed while the heart isbeating, either ring valve 230 (FIG. 48b ) of attachment ring 22 orvalve 16 (FIG. 2a ) of valvular structure 12 autonomously close aftercoring knife 140 is pulled out and thereby prevents significant loss ofblood.

Use of coring knife 140 can begin by inserting coring abutment 145oriented as shown in FIG. 53a into the slit previously formed byslitting tool 300. To facilitate insertion into the slit, the plane ofthe coring abutment 145 should be aligned in the same direction as theslit. Establishing the proper alignment can be difficult because thevisual line of sight to the slit could be obstructed by the coring knifeitself, by ring valve 230 (FIG. 48b ) of attachment ring 22, or by valve16 (FIG. 2a ) of valvular structure 12. An alignment feature on theproximal end of attachment ring 22 or valvular structure 12 can be usedby the user to align coring abutment 145 to the slit in the heart. Thealignment feature can be in the form of indentations 230 (FIG. 4a )formed into interface lip 25 at the proximal end of attachment ring 22and/or indelible markings 232 (FIG. 46c ) in a contrasting color appliedon interface lip 25. The alignment feature can be in the form ofcoupling grooves 71 (FIG. 11a ) or alignment groove 497 (FIGS. 56a and57a ) formed into the proximal end of valvular structure 12 or be in theform of indelible markings applied to the proximal end of valvularstructure 12. A corresponding feature on coring knife case 141, such asa protrusion and/or indelible markings, can be visually aligned orphysically engaged with the alignment feature on attachment ring 22 orvalvular structure 12.

As previously discussed, while the user depresses release trigger 362,slide assembly 370 can be moved forward to a point where forward edge396 of coring knife case 141 touches or is just above the heart tissue398. Positioning forward edge 396 to the desired position relative tothe surface of the heart may be difficult to perform visually if theline of sight to the heart surface is obstructed by coring knife 140,valvular structure 12, and/or attachment ring 22.

As shown in FIG. 54, stop feature 410 can be located on coring knifecasing 141 at a predetermined distance 412 from forward edge 396 ofcoring knife case 141. Stop feature 410 prevents forward edge 396 frompushing into the heart when slide assembly 370 is being positionedwithin attachment ring 22. Stop feature 410 can include protrusions 411sized and shape to fit within the alignment feature on attachment ring22 or valvular structure 12, and/or can include indelible markings foraligning coring abutment 145 with the slit in the heart.

In some embodiments, predetermined distance 412 is equivalent to or afew millimeters less than the longitudinal height of attachment ring 22.The longitudinal height of an exemplary attachment ring is indicated byarrow 348 in FIG. 46d . In use, coring knife 140 can be inserted by asurgeon or other user into attachment ring 22 secured to the heart, withno valvular structure 12 attached to attachment ring 22. When stopfeature 410 abuts interface lip 25 of attachment ring 22, the user willknow that forward edge 396 of coring knife case 141 is located at theproper position. Thereafter, the user can let go of release trigger 362to lock coring knife case 141 in place, then rotate knob 385 to extendcoring blade 137 out of coring knife case 141 and into the heart.

In some embodiments, predetermined distance 412 is equivalent to or afew millimeters less than the longitudinal stack height of valvularstructure 12 and attachment ring 22. The longitudinal stack height of anexemplary assembly of valvular structure 12 and attachment ring 22 isindicated by arrow 350 in FIG. 2b . In use, coring knife 140 can beinserted by a user into valvular structure 12 and attachment ring 22which has been attached to the heart. When stop feature 410 abuts theproximal end of valvular structure 12, the user will know that forwardedge 396 of coring knife case 141 is located at the proper position.Thereafter, the user can let go of release trigger 362 to lock coringknife case 141 in place, then rotate knob 385 to extend coring blade 137out of coring knife case 141 and into the heart.

Stop feature 410 can be an annular flange which can be an integral partof or permanently affixed to coring knife casing 141. Alternatively,stop feature 410 can be movable along coring knife casing 141 to allowpredetermined distance 412 to be adjusted if desired.

Referring again to FIG. 54, coring abutment 145 has abutment surface 414that is substantially flat or planar. Abutment surface 414 faces coringknife case 141 after control lever 364 has been pivoted upward. In use,abutment surface 414 supports the interior surface of the heart ascoring blade 137 rotates, extends out of coring knife case 141, and cutsfrom the exterior surface of the heart. Coring blade 137 ultimatelypresses against abutment surface 414 when cutting is complete.

In other embodiments, such as shown in FIG. 55, abutment surface 414 hasa raised central portion 416 and tapered edges 418 at the outercircumference of coring abutment 145. As coring blade 137 rotates andmoves closer to abutment surface 414, raised central portion 416 entersinto coring blade 137 and tapered edges 418 abut forward edge 396 ofcoring blade. Raised central portion 416 and tapered edges 418 align thecenter of abutment surface 414 with the center of forward edge 396 ofcoring blade 137. Raised central portion 416 and tapered edges 418prevent misalignment in which a portion of forward edge 396 extendsbeyond the outer circumference of coring abutment 145 and fails to pressagainst abutment surface 414. Abutment surface 414 can be convex,spherical, conical or other shape having raised central portion andtapered edges.

In FIGS. 56a-56d , another embodiment of valvular structure 12 is shownhaving a spring-loaded hinge. Valvular structure 12 is shown withattachment ring 22 in FIGS. 56a and 56b . Valvular structure 12 is shownwithout attachment ring 22 in FIGS. 56c and 56d . Valvular structure isdivided into two halves which are hinged together at one end and havelocking features at the other end. The hinge facilitates installationonto and removal from attachment ring 22, as shown in FIG. 56b . Eachhalf of valvular structure 12 includes half of housing 18 and half ofvalve 16. Housing 18 encases valve 16 which has a quadcupsidconfiguration. Valve 16 can be as described in connection with FIGS.10a-10e, 12a-15f or any of the previously described embodiments. In use,housing 18 encases interface lip 25 of attachment ring 22. Attachmentring 22 can be as described in connection with FIG. 4a, 4b, 7a, 7b or 46a-46 c.

As shown in FIG. 56b , housing first portion 46 and housing secondportion 54 form two longitudinal halves of housing 18. The longitudinalhalves are formed by a “cut” that runs along longitudinal axis 187.Housing first portion 46 and housing second portion 54 are separated byan imaginary plane coincident with longitudinal axis 187. Housing firstportion 46 and housing second portion 54 each have, at one end thereof,first and second hinge members 450 a,b that mate with each other and arepivotally connected to each other by hinge pin 452. Housing firstportion 46 and housing second portion 54 each have, at the opposite endthereof, first and second lock members 454 a,b which are locked togetherby slide member 456. Slide member 456 is slidably coupled first lockmember 454 a. Slide member 456 has groove 460 sized and shaped toreceive rib 462 on second lock member 454 b. When housing 18 is closed,as shown in FIG. 56a , slide member 456 is at a distal position in whichrib 462 is retained within slide member 456, thereby keeping housingfirst portion 46 and housing second portion 54 closed and sealedtogether. To open housing 18, a user moves slide member proximally inthe direction of arrow 464 (FIG. 56a ), which disengages slide member456 from rib 462 and allows housing first portion 46 and housing secondportion 54 to pivot on hinge pin 452 and open as shown in FIG. 56b .Slide member 456 includes longitudinal rib 457 which a user can graspwith his/her fingers or a tool in order to move slide member 456.

Housing channel 58 runs through the center of housing 18, through valve16 and communicates with ring channel 14 of attachment ring 22. Housingfirst portion 46 includes de-airing port 62 which includes athrough-hole that extends from the exterior of housing 18 to the portionof housing channel 58 between valve 16 and attachment ring 22.

The interior of housing first portion 46 and housing second portion 54can be mirror images of each other, with the exception of the de-airingport through hole. Thus features shown add/or described for housingfirst portion 46 is present in housing second portion 54, and viceversa. The interior of housing first portion 46 and housing secondportion 54, in combination, can be rotationally symmetric aboutlongitudinal axis 187. Thus, features within housing channel 58 extendfor about 180 degrees on housing first portion 46 and about 180 degreeson housing second portion 54.

When housing 18 is closed, interface lip 25 of attachment ring 22 isretained within interface groove 466. Interface groove 466 is formedbetween distal flange 468 and guide flange 470. Proximal facing surface472 of guide flange 470 can be sloped so as to guide slitting tool 300or coring knife 140 into attachment ring 22. A pair of proximal flanges474 form valve groove 61 which retains valve shoulder 59 of valve 16.

When housing 18 is closed, first gasket 476 and second gasket 478 arecompressed and form a fluid-tight seal between housing first portion 46and housing second portion 54. First gasket 476 is located adjacentfirst and second hinge members 450 a,b. Second gasket 478 is locatedadjacent first and second lock members 454 a,b. First gasket 476 andsecond gasket 478 can be made of a flat piece of silicone rubber foam orother resilient polymer material having edges which match the interioredges of housing 18, including edges of distal flange 468, guide flange470, and proximal flanges 474. A first pair of handles 480, each in theform of a longitudinal rib, are located adjacent to lock members 454 a,454 b and protrude from housing first portion 46 and housing secondportion 54. A user can pinch handles 480 together, using his/her fingersor a tool, when closing housing 18 in order to compress first gasket 476and second gasket 478 sufficiently to allow slide member 456 to be slidonto rib 462.

FIGS. 56c and 56d are views of the proximal end of housing 18. A secondpair of handles 482 are located adjacent to hinge members 450 a, 450 band hinge pin 452. As shown in FIG. 56a , each handle 482 has a base 484adjacent the distal end of housing 18 and longitudinal wing member 486that extends proximally from base 484. Base 484 and wing member 486 areattached to housing 18. Through hole 488 is formed into base 484. Groove490 extends from through hole 488 and onto wing member 486. Torsionspring 492 (FIG. 56c ) is disposed between handles 482. Straight ends496 of torsion spring 492 are retained within grooves formed in wingmembers 486. Torsion spring 492 is under compression such that straightends 496 constantly push wing members 486 apart, thereby biasing housing18 closed. Hinge pin 452 extends through helical segment 494 of torsionspring 492, thereby preventing torsion spring 492 from detaching fromwing members 486. After moving slide member 456 to a proximal positionin which rib 462 is released, a user may squeeze handles 462 together toovercome torsion spring 492 and thereby open housing 18 as shown in FIG.56d . The user may engage a tool on grooves 490 and/or through holes 488in order to squeeze handles 462 together.

Alignment groove 497 is formed into proximal edge 498 of each of housingfirst portion 46 and housing second portion 54. Alignment groove 497 canbe sized and shape to receive protrusions 346 on the exterior surface ofthe slitting tool 300 (FIG. 52a ) and protrusions 411 on the exteriorsurface of coring knife 140 (FIG. 54). Engaging slitting tool 300 andcoring knife 140 into grooves 497 can ensure that coring abutment 145 ofcoring knife 140 is aligned with the slit previously formed by flatblade 326 of slitting tool 300. Alignment marking 498 is embossed on theside of each of housing first portion 46 and housing second portion 54to facilitate alignment of slitting tool 300 and coring knife 140.

In FIGS. 57a-57d , there is shown an embodiment of valvular structure 12which can be installed with C-clamp tool 600 (FIG. 58a ). Valvularstructure is divided into two identical halves which can be lockedtogether and separated, as desired, to facilitate installation onto andremoval from attachment ring 22 (not shown in FIGS. 57a-57b ). Housing18 encases valve 16 which has a quadcupsid configuration. Valve 16 canbe as described in connection with FIGS. 10a-10e, 12a-15f or any of thepreviously described embodiments. In use, the proximal end of attachmentring 22 can abut the distal end of housing 18, instead of being encasedwithin housing 18. Housing 18 is rotationally symmetric aboutlongitudinal axis 187 such that for each feature on housing 18 there isan identical feature located 180 degrees away.

Housing first portion 46 and housing second portion 54 are identical toeach other so for any feature shown and/or described for one of them,there is a corresponding feature present on the other. As shown in FIG.57b , opposite ends of housing first portion 46 have hinge members 510which interlock with that of housing second portion 54. Each hingemember 510 has a through hole 511. Interlocking hinge members 510 areheld together by slidable hinge pin 520 having a first straight leg 522and a second straight leg 524. First straight leg is slideable withinthrough holes 511 of hinge members 510. Second straight leg 524 isslideable within through hole 526 formed in wing 528 at the proximal endof housing 18.

When housing 18 is closed, as shown in FIG. 57a , each hinge pin 520 isin a distal position, and first straight leg 524 holds hinge members 510together. To open housing 18, a surgeon or other user may move hinge pin520 proximally from the distal position, in the direction of arrow 530,which causes first straight leg 522 to move and allow hinge members 510to pull apart from each other, as shown in FIG. 57b . Foot member 532 onsecond straight leg 524 abuts wing 528, which prevents hinge pin 520completely pulling out and detaching from housing 18. When one of thehinge pins 520 is moved proximally and the other hinge pin 520 is in thedistal position, housing first portion 46 and housing second portion 54can pivot apart from each other so that housing 18 opens. When bothhinge pins 520 are moved proximally, housing first portion 46 andhousing second portion 54 can completely detached from each other. Whenhousing first portion 46 and housing second portion 54 are detached orpivoted apart from each other, valve 16 can be pulled out from betweenproximal flanges 534 within housing channel 58 and be completelyremoved.

Housing first portion 46 and housing second portion 54 each havede-airing port 62 which includes a through-hole the extends from theexterior of housing 18 to the portion of housing channel 58 betweenvalve 16 and the distal end of housing 18. Housing first portion 46 andhousing second portion 54 each have gasket 536, alignment pins 538, andalignment holes 540. Alignment pins 538, and alignment holes 540 arelocated on opposite ends of housing first portion 46 and housing secondportion 54, so that alignment pins 538 of one of housing portion isreceived into alignment holes 540 of the other housing portion. Whenhousing 18 is closed, gasket 536 is compressed and forms a fluid-tightseal between housing first portion 46 and housing second portion 54.Gasket 536 can be bonded to the housing portion and can be made of aflat piece of silicone rubber foam or other resilient polymer materialhaving edges which match the interior edges of housing 18, including thecontours of proximal flanges 534 and base flange 552.

Alignment groove 542 is formed into proximal edge 544 of each of housingfirst portion 46 and housing second portion 54. Alignment groove 542 canbe sized and shape to receive protrusions 346 on the exterior surface ofthe slitting tool 300 (FIG. 52a ) and protrusions 411 on the exteriorsurface of coring knife 140 (FIG. 54). Engaging slitting tool 300 andcoring knife 140 into grooves 496 can ensure that coring abutment 145 ofcoring knife 140 is aligned with the slit previously formed by flatblade 326 slitting tool 300.

Referring to FIG. 57b , alignment groove 542 can be configured in such away that a cylindrical protrusion can be pushed distally into proximalopening 544 and snapped into and retained within channel 546. Retentionis provided by proximal opening 544 which has width 548 that is slightlysmaller than width 550 of channel 546. In some embodiments, valvularstructure 12 can be carried at the end of an installation tool havingcylindrical protrusions engaged with alignment grooves 542. Theinstallation tool can be used to position valvular structure 12 at adesired position adjacent attachment ring 22 during a surgicalprocedure. For example and without limitation, the installation tool canbe slitting tool 300.

FIGS. 57c and 57d show views of the distal end of housing 18 whenclosed. Housing first portion 46 and housing second portion 54 each havebase flange 552. Base flange 552 is rigid and can be made of the samematerial used to form the remainder of housing 18. Base gasket 554 isadhered to base flange 552. Base gasket 554 can be made of a flat pieceof silicone rubber foam or other resilient polymer material having edgeswhich substantially match the edges of base flange 552.

Base flange 552 is sized and shaped to fit within rotatable withinC-clamp 600 (FIG. 58c ), which will be described below. Inner surface556 of each base flange 552 has the shape of a half circle sized toallow slitting tool 300, coring knife 140, and inflow conduit 10 to passthrough. The Outer surface of base flange 552 includes an outer curvedsurface 558 between two outer straight surfaces 560. Outer straightsurfaces 560 are substantially parallel to each other and are offsetfrom each other by distance 562 (FIG. 57d ). The curvature of outercurved surface 558 is defined by diameter 564. When the housing 12 isclosed, diameter 564 corresponds to the distance, as measured throughthe geometric center 566 of housing, between outer curved surface 558 onhousing first portion 46 and outer curved surface 558 on housing secondportion 54. Diameter 564 is greater than distance 562.

Outer curved surface 558 and outer straight surface 560 define the edgeof compression surface 561 of base flange 552. Compression surface 561(FIGS. 57a and 57b ) faces in the proximal direction and, as explainedbelow, can be pushed by C-clamp 600 to compress base gasket 554 ontoattachment ring 22. Side groove 568 is formed into a portion of theouter surface of base flange 552 and is disposed distal to compressionsurface 561. Stop wall 570 at one end of side groove 568 is formed intocurved surface 558. Side groove 568 extends from stop wall 570 along thecircumference of curved surface 558 until side groove 568 opens onto andintersects one of the outer straight surfaces 560 at groove entrancepoint 572.

FIGS. 58a-58e, 59a and 59b show C-clamp 600 used for stabilizingattachment ring 22 after attachment ring 22 has been secured the heart,and for aligning and clamping valvular structure 12 onto attachment ring22. C-clamp 600 facilitates alignment and control during use of slittingtool 300 and coring knife 140 and during insertion of inflow conduit 10into attachment ring 22.

C-clamp 600 can be attached to a handle 602 for inserting C-clamp 600into the body of a patient. Handle 602 can be of sufficient length toreach the apex of the heart with a portion of the handle extending outof the patient's chest no more than about 5 to 6 inches from the chestsurface. In some embodiments, handle 602 is rigid and has a fixedcurvature. In some embodiments, the curvature of the handle 602 can beadjusted and locked by the user. In some embodiments, as shown in FIG.58b , handle 602 can be articulated and have a plurality of segments 604connected to each other by joints 606 which can be selectively loosenedand locked by knob 608 to allow the curvature of handle 602 to beadjusted. Knob 608 can be configured to tighten joints 606 and/or adjusttension in one or more cables that run through the center of segments604, wherein movement of joints depend on the amount of tension in thecables. After the curvature of handle 602 is locked and C-clamp 600 isin the desired position within the patient, handle 602 can be secured toa chest retractor attached to the patient.

Referring to FIGS. 58c and 58d , shoulder segment 610 of C-clamp 600 isattached to handle 602. Two arm segments 612 extend from shouldersegment. Free end 614 of arm segments 612 are spaced apart from eachother and define side opening 616 of C-clamp 600. Two finger members 618form the tips of free end 614 of each arm segment 612. Side slot 620 isformed between finger members 618. Distal offset distance 622 separatesthe tips of finger members 618 of one arm segment from the tips offinger members 618 of the other arm segment. Distal offset distance 622corresponds to the width of distal opening 624 at the base of C-clamp600. Edges of distal opening 624 form a U-shape, as shown in FIG. 58d ,which includes distal linear edges 625 that are parallel to each otherand are offset from each other by distal offset distance 622. Distalgroove diameter 648 a (FIG. 58e ) is greater than distal offset distance622. Side opening width 623 separates the base surface of side slot 620of one arm segment from the base surface of side slot 620 of the otherarm segment. In use, interface lip 25 of the attachment ring 22 passesthrough side opening width 623, and distal opening 624 receivesattaching ring wall 29.

The shoulder segment 610 and the arm segments 612 form clamp body 601.Distal groove 632 and proximal groove 644 in clamp body 601 formcylindrical surfaces 628 a, 628 b and ledge surfaces 626 a, 626 b thatintersect each other. In illustrated embodiment, ledge surfaces 626 a,626 b are planar. Cylindrical surfaces run substantially parallel toclamp longitudinal axis 630 and interface with circumferential surfacesof attachment ring 22 and valvular structure 12 when in use. Distalcylindrical surface 626 a of distal groove 632 has a curvature which canbe concentric with the curvature of proximal cylindrical surface 626 bof proximal groove 644. Ledge surfaces 626 a, 626 b are substantiallyplanar and perpendicular to clamp longitudinal axis 630 and interfacewith distal or proximal facing surfaces of attachment ring 22 andvalvular structure 12 when in use. In other embodiments, ledge surfaces626 a, 626 b may include curves or indentations.

FIGS. 59a and 59b show C-clamp 600 with various devices. In use, C-clamp600 is advanced toward attachment ring 22 which has already been securedto the heart. C-clamp 600 is advanced so that attachment ring 22 passesthrough side opening 616. Interface lip 25 of attachment ring 22 passesbetween fingers 618 and into side slot 620, and ring wall 29 ofattachment ring 22 passes through distal opening 624 of C-clamp. Sideopening width 623 between side grooves 620 is about the same as orslightly larger than the outer diameter of interface lip 25 ofattachment ring 22. Distance 622 between the tips of fingers 618 isabout the same as or slightly larger than the outer diameter of ringwall 29 of attachment ring 22. C-clamp 600 is positioned so thatinterface lip 25 is seated within distal groove 632 of C-clamp 600.Distal ledge surface 626 a of distal groove 632 supports interface lip25.

Proximal opening 634 (FIG. 59a ) of C-clamp 600 is shaped and sized toreceive base flange 552 and base gasket 554 of valvular structure 12 ofFIGS. 57a-57d . Exterior surface 626 c of arm segments 612 of C-clamp600 include linear edges 636 and curved edge 638 which correspond inshape to outer curved surface 558 and outer straight surfaces 560 ofbase flange 552. Linear edges 636 are parallel to each other. Curvededge 638 intersects proximal cylindrical surface 628 b. To allow baseflange 552 to pass through proximal opening 634, linear edges 636 andcurved edge 638 have dimensions which about the same as or slightlylarger than outer curved surface 558 and outer straight surfaces 560 ofbase flange 552. Proximal offset distance 642 separates linear edges 636and is about the same as or slightly larger than distance 562 (FIG. 57d) between straight surfaces 560 of base flange 552. Proximal offsetdistance 642 is less than proximal groove diameter 648 a.

As shown in FIG. 58d , the curvature of the distal cylindrical surface628 a extends between 180 degrees and 300 degrees. In the illustratedembodiment, distal cylindrical surface 628 a extends about 270 degrees.The curvature of the proximal cylindrical surface 628 b extends between180 degrees and 300 degrees. In the illustrated embodiment, proximalcylindrical surface 628 b extends about 270 degrees.

In use, valvular structure 12 is moved distally toward C-clamp 600 inthe direction of arrow 640 (FIG. 59a ), which base flange 552 facingC-clamp 600. Valvular structure 12 is rotated about its longitudinalaxis until outer straight surfaces 560 of base flange 552 aresubstantially parallel with linear edges 636 of C-clamp 600, therebyallowing base flange 552 and base gasket 554 to pass through proximalopening 634. Base gasket 554 contacts interface lip 25 of attachmentring 22. Base flange 552 is seated within proximal groove 644 defined byproximal ledge surface 626 b, proximal cylindrical surface 628 b, andproximal compression surface 650 which intersect each other. Proximalcylindrical surface 628 b extends from side slot 620 on one arm segmentto side slot 620 on the other arm segment, and forms a circular shapehaving proximal groove diameter 648 b (FIG. 58d ) that is about the sameas or slightly larger than diameter 564 (FIG. 57d ) of outer curvedsurface 558 of base flange 552. As shown in FIG. 58d , proximal groovediameter 648 b is greater than proximal offset distance 642 whichseparates linear edges 636. A portion of proximal cylindrical surface628 b is located below (distal to) linear edges 636 and intersectsproximal compression surface 650, as shown in FIG. 58e (side view ofC-clamp). A pair of stop pins 652 (FIGS. 58d and 59a ) protrude radiallyinward from the portion of proximal cylindrical surface 628 b belowlinear edges 636.

Referring to FIG. 58e , distal cylindrical surface 628 a of distalgroove 632 has a curvature having a distal groove diameter 648 a whichis about the same as or slightly greater than the outer diameter ofattaching ring wall 29 of attachment ring 22. The proximal groovediameter 628 b is greater than the distal groove diameter 628 a.Proximal compression surface 650 faces proximal ledge surface 626 b.Distal opening 624 extends through distal ledge surface 626 a. Proximalopening 634 extends through compression surface 650.

After valvular structure 12 is seated within distal groove 644, valvularstructure 12 can be rotated relative to C-clamp 600 about clamplongitudinal axis 630 in the direction of arrow 654 (FIG. 59b ). Toallow for rotation, valvular structure 12 can be pushed distally in thedirection of arrow 640 to compress base gasket 554 of valvular structure12 against interface lip 25 and cause compression surface 561 of baseflange 552 to be longitudinally aligned with or move slightly belowproximal compression surface 650 of C-clamp 600. Thereafter, valvularstructure 12 can be rotated in the direction of arrow 654. Each Stop pin652 of C-clamp 600 prevents rotation in the opposite direction. Duringrotation, stop pin 652 is received within side groove 568 in base flange552. Stop pin 652 enters groove entrance point 572. As valvularstructure 12 is rotated, stop wall 570 at the end of side groove 568moves toward stop pin 652 until they abut each other, which prevents anyfurther rotation. Rotation stops when valvular structure 12 has rotatedone quarter turn (or 90 degrees). After rotation has stopped, as shownin FIG. 59b , outer curved surface 558 of base flange 552 is locatedbelow (distal to) linear edges 636 of C-clamp 600. Compression surface561 of base flange 552 engages proximal compression surface 650 ofC-clamp 600, which keeps base gasket 554 of valvular structure 12compressed and sealed against interface lip 25 of attachment ring 22.

As shown in FIG. 59b , alignment assembly 660 is disposed withinproximal edge 544 of valvular structure 12. Protrusions 662 (one visiblein FIG. 59a ) of alignment assembly 660 extend radially outward and areengaged within alignment groove 542 is formed into proximal edge 544.Alignment assembly 660 can be part of a tool having a tip that extendsinto valvular structure 12 and attaching ring 22. Alignment assembly 660can be attached to coring knife casing 141.

FIGS. 60a-60c show other embodiments of aortic punch 126. Aortic punch126 includes punch casing 680, handle 682, guide cylinder 684, cylinderstem 686, and punch head 688. Longitudinal axis 681 runs through thecenter of guide cylinder 684. Cylinder stem 686 connects punch head 688to guide cylinder 684. Guide cylinder 684 slides within internal channel690 within punch casing 680. Guide cylinder 684 maintains the traveldirection of punch head 688 parallel to longitudinal axis 681. Handle682 passes through and is secured to guide cylinder 684. Handle 682extends out of slots 692 formed through punch casing 680. A surgeon orother use can slide guide cylinder 684 within punch casing 680 bymanipulating handle 682. Hollow blade 694 is disposed at the forward endof punch casing 680. Internal channel 690 extends through blade 694where it forms blade opening 696.

As shown in FIG. 60b , internal channel 690 has an oblongcross-sectional shape as viewed from longitudinal axis 691. Thecross-sectional shape is defined by two parallel sides 700 connected toeach other by semi-circle ends 702. Semi-circle ends 702 are equal indiameter. Each semi-circle ends 702 has diameter 698 less than thelength of the sides 700. The shape of blade opening 696 is defined byblade cutting edge 704. When viewed from longitudinal axis 681, bladecutting edge 704 has substantially the same oblong shape (with parallelsides and semi-circle ends) and same dimensions as the cross-sectionalshape of internal channel 690. Punch head 688 is shaped and sized topass through blade opening 696. The contours of outer perimeter 706 ofpunch head 688 includes parallel sides and semi-circle ends which formthe same oblong shape as blade cutting edge 704. Thus, when viewed fromlongitudinal axis 681, punch head 688 has the same oblong shape as thecross-sectional shape of the internal channel 690.

In use, punch head 688 can be inserted within a small incision throughthe aorta or other anatomical vessel, such that punch head 688 islocated within the lumen of the vessel, cylinder stem 686 passes throughthe incision, and blade 694 remains outside the vessel. Thus, the wallof the vessel is disposed between punch head 688 and blade 694. The usermay then pull handle 682 rearward in the direction of arrow 708 whichmoves punch head 688 toward blade cutting edge 704. The wall of thevessel is cut or sheared as punch head 688 travels past blade cuttingedge 704. Depending on the shape of blade cutting edge 704 and punchhead 688, cutting or shearing of the vessel wall may not occur at thesame time and may occur progressively as different parts of the bladecutting edge 704 and punch head 688 move past each other. A hole is madethrough the vessel wall when punch head 688 has moved completely withinblade 694.

FIGS. 60c-60e show variations in the side profile shape of blade cuttingedge 704 and punch head 688. The side profiles correspond to views ofgreatest dimension 705 of blade cutting edge 704 in a directionperpendicular to longitudinal 681. In FIG. 60c , punch head outerperimeter 706 lies on a plane substantially perpendicular tolongitudinal axis 681, and blade cutting edge 704 has a convex sideprofile. The convex side profile of blade cutting edge 704 includes sidesegments 712 and central segment 714 that extends in front of sidesegments 712. Thus, when punch head 688 moves toward blade 694, cuttingor shearing occurs first at the central portion of the vessel walladjacent central segment 714 and cylinder stem 686, then at the portionof the vessel wall adjacent side segments 712.

In FIG. 60d , punch head outer perimeter 706 has a convex side profileand blade cutting edge 704 lies on a plane substantially perpendicularto longitudinal axis 681. The convex side profile of punch head outerperimeter 706 includes side segments 716 and central segment 718 thatextends in front of side segments 716. Thus, when punch head 688 movestoward blade 694, cutting or shearing occurs first at the centralportion of the vessel wall adjacent central segment 718 and cylinderstem 686, then at the portion of the vessel wall adjacent side segments712.

For the side profile shapes in FIGS. 60c and 60d , the central portionof the vessel wall, closest the cylinder stem 686, is cut first.However, side profile shapes in FIGS. 60c and 60d produce holes in thevessel wall which are different in shape. As shown in FIG. 61a , theside profile shapes in FIG. 60c result in a substantially oblong shapedhole 720 through a vessel wall 722. Hole 720 has substantially parallelsides and semi-circle ends. The oblong shaped hole 720 can be thepreferred shape for attaching outflow conduit 2 to an aorta. As shown inFIG. 61b , the side profile shapes in FIG. 60d result in a substantially“dog-bone” shaped hole 724 through vessel wall 726. Hole 724 has curvedsides that make middle area of hole 724 narrower than the ends of hole724.

In FIG. 60e , punch head outer perimeter 706 lies on a planesubstantially perpendicular to longitudinal axis 681, and blade cuttingedge 704 has a concave side profile. The concave side profile of bladecutting edge 704 includes central segment 714 and side segments 712 thatextend in front of central segment 714. Thus, when punch head 688 movestoward blade 694, cutting or shearing occurs first at the portions ofthe vessel wall adjacent side segments 712, then at the portion of thevessel wall adjacent central segment 714 and cylinder stem 686. The sideprofile shapes in FIG. 60e result in a substantially “dog-bone” shapedhole through a vessel wall, such as shown in FIG. 61 b.

FIGS. 62a-65d show various embodiments of coring knife 140 havingstructural elements that function in the same manner as correspondingelements described in connection with FIGS. 53a-53f . Each embodiment isshown in a sequence of four figures (with letters a through d) whichcorrespond to the operational steps described in connection with FIGS.53a and 53d -53 f.

In FIGS. 62a-62d , an embodiment of coring knife 140 is shown having apistol-type grip configuration. In the starting configuration shown inFIG. 62a , release trigger 362 is covered by abutment control lever 364which prevents inadvertent actuation of release trigger 362 while coringabutment 145 is being inserted through a slit formed in the heart.

In FIGS. 63a-63d and 64a-64d , other embodiments of coring knife 140 isshown having an in-line grip configuration. Grip 360 is substantiallyparallel to longitudinal axis 366. In the starting configuration shownin FIGS. 63a and 64a release trigger 362 is covered by abutment controllever 364 which prevents inadvertent actuation of release trigger 362while coring abutment 145 is being inserted through a slit formed in theheart.

In FIGS. 65a-65d , an embodiment of coring knife 140 is shown having apistol-type grip configuration. Release trigger is located on centralshaft 372 and is in the form of knob 362. Standoff 365 (FIG. 65b )protrudes from abutment control lever 364. In the starting configurationshown in FIG. 65a , standoff 365 abuts the rear of knob 362, whichprevents knob 362 for inadvertently being pressed while coring abutment145 is being inserted through a slit formed in the heart.

Any elements described herein as singular can be pluralized (i.e.,anything described as “one” can be more than one). Attaching, coupling,and joining can be used interchangeably within this description. Anyspecies element of a genus element can have the characteristics orelements of any other species element of that genus. The above-describedconfigurations, elements or complete assemblies and methods and theirelements for carrying out the invention, and variations of aspects ofthe invention can be combined and modified with each other in anycombination.

What is claimed is:
 1. A coring knife comprising: a coring knife casing;a coring blade including a cylindrical wall defining a circular cuttingedge and a hollow interior, the coring blade movable into and out of thecoring knife casing, the coring blade configured to move out of thecoring knife casing when the coring blade is rotated relative to thecoring knife casing; a control sleeve attached to the coring blade, thecontrol sleeve having a helical slot and disposed within the coringknife casing, the coring knife casing including a guide peg that extendsinto the helical slot; and a coring abutment capable of being locatedforward of the cutting edge, the coring abutment attached to a supportextending longitudinally into the coring blade, wherein rotation of thecontrol sleeve relative to the coring knife casing, with the guide pegin the helical slot, causes the coring blade to extend out of the coringknife casing, and wherein the cutting edge is configured to cut tissueagainst a surface of the coring abutment, the cutting edge and thesurface of the coring abutment are movable relative to each other, andthe surface of the coring abutment is configured to tilt relative to thecutting edge and the support, such that a first point on the surface ofthe coring abutment moves from a first point initial position to a firstpoint subsequent position that is longitudinally closer to the coringblade than the first point initial position, and a second point on thesurface of the coring abutment moves from a second point initialposition to a second point subsequent position that is longitudinallyfurther away from the coring blade than the second point initialposition.
 2. The coring knife of claim 1, further comprising a handleattached to the support, wherein linear movement of the handle towardthe cutting edge moves the coring abutment away from the cutting edge,and linear movement of the handle away from the cutting edge moves thecoring abutment toward the cutting edge.
 3. The coring knife of claim 1,further comprising a handle attached to the support, wherein twistingmovement of the handle moves the cutting edge away from or closer to thecoring abutment.
 4. The coring knife of claim 1, further comprising ahandle or lever connected to the coring abutment, wherein tiltingmovement of the handle or lever pivots the coring abutment relative tothe cutting edge.
 5. The coring knife of claim 1, further comprising anabsorbent material within the coring blade, the absorbent materialconfigured to absorb blood.
 6. The coring knife of claim 1, wherein thecoring abutment is sized for an interference fit against the cuttingedge of the coring blade.
 7. The coring knife of claim 1, wherein thecoring abutment includes a convex abutment surface.
 8. The coring knifeof claim 1, further comprising a foreblade coupled to the coringabutment, wherein the coring abutment is disposed between the forebladeand the cutting edge.
 9. The coring knife of claim 1, further comprisinga grip, an internal sleeve, and a central shaft fixedly attached to thegrip and extending into the internal sleeve, wherein a slide assembly isformed collectively by the coring knife blade, the coring knife casing,and the internal sleeve, and wherein the entire slide assembly isconfigured to move axially relative to the central shaft and to beselectively positioned and locked at any one of a plurality of locationson the central shaft.
 10. The coring knife of claim 9, wherein aplurality of holes arranged linearly are formed into the internalsleeve, and a detent mechanism within the central shaft releasablyengages at least one of the holes to lock the slide assembly at any oneof the plurality of locations on the central shaft.
 11. The coring knifeof claim 9, wherein a linear slot is formed into the internal sleeve,and a pin extends from the central shaft into the linear slot to preventrotation of the internal sleeve relative to the central shaft when thecontrol sleeve is rotated relative to the coring knife casing and theinternal sleeve.
 12. The coring knife of claim 11, wherein the coringblade is configured to move out of the coring knife casing when thecontrol sleeve is rotated relative to the coring knife casing and theinternal sleeve.
 13. The coring knife of claim 9, wherein the internalsleeve extends into the coring knife casing.
 14. The coring knife ofclaim 1, wherein the coring knife casing includes a stop featureconfigured to fit in an alignment feature of a separate device foraligning the coring knife prior to extension of the coring blade out ofthe coring knife casing.
 15. The coring knife of claim 14, furthercomprising a grip, wherein the coring knife casing and the coring bladeare configured such that the coring knife casing and the coring bladecan move simultaneously together toward the coring abutment and belocked at any one of a plurality of locations between the grip and thecoring abutment prior to extension of the coring blade out of the coringknife casing.
 16. The coring knife of claim 1, further comprising acontrol arm configured to tilt the coring abutment from a first tiltposition to a second tilt position, wherein the control arm is pivotallyconnected to the coring abutment.
 17. The coring knife of claim 1,wherein the coring abutment is configured to compress tissue against thecutting edge.
 18. The coring knife of claim 1, wherein the coringabutment is capable of being spaced apart from the cutting edge to allowtissue to be disposed between the coring abutment and the cutting edge,the coring abutment is configured to tilt for insertion of the coringabutment through tissue while the coring abutment is at a first tiltposition, and the cutting edge is configured to cut tissue against thecoring abutment while the coring abutment is at a second tilt position.19. A coring knife comprising: a grip; a coring abutment connected tothe grip; and a slide assembly connected to the grip, the slide assemblyincluding a coring blade with a circular cutting edge, a control sleeveconnected to the coring blade, and a coring knife casing containing thecoring blade, wherein the control sleeve has a helical feature engagedto the coring knife casing such that rotation of the control sleeverelative to the coring knife casing urges the control sleeve to move ina forward direction toward the coring abutment, and the movement of thecontrol sleeve in the forward direction extends the coring blade out ofthe coring knife casing into contact with the coring abutment, andwherein the coring knife casing, the control sleeve, and the coringblade are configured to be moved together, relative to the grip, in theforward direction toward the coring abutment prior to extension of thecoring blade out of the coring knife casing.
 20. The coring knife ofclaim 19, wherein the slide assembly includes a stop feature configuredto fit in an alignment feature of a separate device for aligning thecoring knife prior to extension of the coring blade out of the coringknife casing.
 21. The coring knife of claim 19, wherein the coringabutment is pivotally attached to a support that extends into the coringblade, and wherein the coring abutment is configured to pivot relativeto the support.